PPH Flashcards
Risk of PPH
5-15%
First PPH in 2nd or third preg - 5%
Recurrence of PPH 15%
Mortality from obs haemorrhage
12 in 100,000
5 in 100,000 PPH
Define PPH - minor/major/primary/secondary
minor PPH >500ml
Major PPH >1000ml or any that causes haemodynamic compromise
Primary - within 24h
secondary - within 6 weeks
Bloods = PPH = >10 point drop in HB
Risks for tone issues causing PPH
LABOUR:
Long labour
Induction of labour
Rapid labour
Pyrexia/chorio
WOMAN:
Multiparous
Uterine abnormalities
BABY:
Twins
Polyhydramnios
LGA
DRUGS:
- Synto
- MgSO4
- nifedipine
Risks for TRAUMA issues causing PPH
LABOUR:
- Quick labour
- Not adequate perineal protection
- Induced/augmented labour
- Instrumental
WOMAN:
- Previous tears
- Short perineum
BABY:
- LGA
- twins
- Malposition
Risks for rupture:
- Previous CS
Risks for inversion
- Cord traction (esp with fundal contraction)
- Short cord
- High parity
- Accreta
Risks for TISSUE issues causing PPH
Accreta
Previous RPOC
Previous CS
High parity
Risks for THROMBIN issues causing PPH
Cooagulation disorders
Pre-eclampsia
HELLP
Abruption
Fetus that died in utero
Management of 3rd stage labour
Primips - within 1 hour
Multips - within 30 minutes
Recommendation - 5 units IV synto or 10 IM. Controlled cord traction
How does delayed cord clamping help baby
reduces fetal anaemia
Especially to reduce fetal tranfusions and interventricular haemorrhage in pre-term babies
How is expectant management of 3rd stage done
immediate skin to skin
women in upright position to give birth to placenta
What is blood volume in pregnancy
100ml/kg
Immediate resus measures for PPH
DRS ABCD
Danger - assess quickly and addres spartner
Response - ?woman conscious
Send for help
A - open?
B - 15L O2
C - IVC, IDS, IVF, bloods
Assess the 4 Ts:
- Tone - fundal massage and give drugs
- Trauma - assess tear and apply pressure and think PAIN RELIEF
- Tissue - is placenta intact? Expel clots
- Thrombin - coag disorder history?
Activation of the massive transfusion protocol if necessary
What could an unclear cause of an unstable PP patient be?
Uterine rupture
Perineal haematoma
Uterine inversion
TAKE TO THEATRE IF NEED TO EXPLORE
What needs to happen prior to bimanual massage?
Insert IDC
What does the massive transfusion protocol include?
What is the criteria?
Transfusing whole blood volume within 24h or HALF blood volume within 4h
Needing 4x unit RBC within 4h or lab evidence of coagulopathy
What are the aims for parameters during a massive obstetric haemorrhage
Ph >7.2
Lactate <4
TEMP >35
Calcium >1.1
Plt>50
INR <1.5
PT/APTT <1.5x normal
Fibrinogen >2
What are the operative measures that can be use for PPH?
Balloon tamponade - foley catheter/rusche balloon/Bakri balloon
Haemostatic suture - B lynch
Ligation of uterine arteries
Ligation of internal ilic arteries
baloon catheterisation of major pelvic vessels
hysterectomy
What are the drugs used for atony
Syntoninon
- 10 units IM or 5 units IV
- 40 units over 4h (1L hartmanns)
- Side effects: N&V
Ergometrine
- 500mcg IM or 250 mcg IV
- CI: hypertension/pre-eclampsia (diastolic >90), retained placenta, heart disease, sepsis, renal or heptic sydfunction
- Side effects: headache, N&V, HTN, chest pain/arrythmias
- Can repeat in 2h
Syntometrine
- 1ml (max 3ml in 24h) - % units synto + 500mcg ergo
- Same SEs
- Same Contraindications
- Can repeat in 2h
Carboprost
- 250mcg IM
- CI: asthma, severe renal/hepatic disease
- Side effects: diarrhoea, fevers
- Can repeat every 15 minutes up to 8 doses
Misoprostol
- 800-1000mcg
- CI: allergy
- Side effects: fever
- Cautions: asthma
TXA
- ASAP when starts bleeding
What is the problem with misoprostol in PPH
SLOW
Oral - 8 minutes (lasts 2h)
SL - 11 minutes (lasts 3h)
rectal - 100 minutes (lasts 4h)
Describe how bi-manual massage is done
one hand on uterus via abdo pushing fundus downwards and one hand (fist) in anterior fornix of vagina
Massage with both hands
When is using a Bakri balloon inappropriate
bleeding from cervical/vaginal trauma
Cervical cancer
uterine rupture
Describe how to put a bakri balloon in
Make sure placenta complete and maks sure bleeding not from vaginal/cervix lacerations.
(pre-warm saline - 500ml in sterile bowl)
- Insert IDC
- Clean vagina/cervix
- Put speculum in and grab anterior cervix and put balloon in
- Insert water, max 500ml
- Gentle trction on balloon and tape to thigh
- If bleeding continues –> surgery
How to take a Bakri balloon out?
Can only stay in fo 24h
Need IV abx as can cause infection
Take water out gradually
How do you look for cervical tears
Get two sponge forceps and work around like a clock to look for tears
