PPH

Question 0

What is the difference between primary and secondary PPH?

Answer 0

Primary is within 24 hours of delivery

Secondary is from birth until 6/52 post partum

Question 1

How is PPH defined?

Answer 1

Blood loss >500 ml after NVD / >1000 ml after C/S

Question 2

List the risk factors for PPH

Answer 2

Previous PPH. (Previous) C/S. Parity >5. Atonic uterus. Neglect active management of 3rd stage. Assisted deliveries. APH. GPH. Severe anaemia. Age >35. Chronic disease. Multiple pregnancy. Obese.

Question 3

What causes an atonic uterus?

Answer 3

Shoulder dystocia. Prolonged labour. Macrosomia. Multiple pregnancy. Polyhydramnios. Exhaustion. Over distention. Uterine infection. Chorioamnionitis.

Question 4

What are the avoidable factors in PPH?

Answer 4

Delay in seeking help. Delay in transport. No attendance. Lack of specific health facilities. Lack of sufficient blood. Inadequate monitoring. Lack of sufficient staff.

Question 5

What are the 4Ts that can cause PPH and give an example of each.

Answer 5

Tone (atonic uterus)
Tissue (RPOC)
Trauma (genital tract lacerations)
Thrombin (coagulation abnormalities either hereditary or acquired)

Question 6

What trauma can cause PPH?

Answer 6

Genital tract trauma (lacerations/ tears on the perineum or in the vagina).
Inverted uterus
Ruptured uterus

Question 7

How do you prevent PPH?

Answer 7

Detect at risk patients. Deliver at appropriate hospital. Detect and rx anaemia antenatally. Active mx 3rd stage. Prevent prolonged labour. Precautions using oxytocin and miso in multips. Avoid inappropriate use of oxytocin. Early latching. Close monitoring for first 2 hours after birth.

Question 8

How to manage PPH?

Answer 8

Call for help. Active management of 3rd stage. Resus. Diagnoses cause of bleeding (4Ts). Control bleeding. Try latch baby. Treat. IV lines. Blood samples. Catheterised and monitor output. Rub up uterus/ bi annual compression. 20u oxytocin in 1l ringers. Give O2.

Question 9

What is done if the placenta is incomplete?

Answer 9

Evacuate the uterus

Question 10

What do you do if the placenta has not delivered?

Answer 10

Repeat CCT and manual removal

Question 11

What do you do if the placenta is completely removed but the uterus remains soft?

Answer 11

Massage and expel clots. Continue oxytocin infusion. IV ergometrine 0.5 mg or repeat 1 amp oxytocin IMI. Miso 400-600 ug PR. PGF2a 5 mg in 10ml saline - 1 ml injected into myometrium. Balloon tamponade.

Question 12

What is done if the bleeding is ongoing?

Answer 12

Examine the patient in theatre. Explore for RPOC. Laparotomy for B-lynch suture or other uterine compression sutures. If that fails, hysterectomy.

Question 13

What is the management plan if the uterus is firm but bleeding continues?

Answer 13

Suture lacerations of the perineum, vagina and cervix.

Question 14

What is done if the uterus is not felt?

Answer 14

Check vagina for inverted uterus, and replace immediately. (Johnson maneuver)
Hydrostatic reduction- infuse warm saline into vagina (O’Sullivans technique)

Question 15

What are signs of haemorrhage?

Answer 15

Pale. Confused. Increased HR with decreased BP. FH abnormalities. Reduced urine output. Obvious or hidden bleeding.

Question 16

What are the causes of PPH following vaginal delivery?

Answer 16

The T’s: tone, trauma, tissue

Uterine atony. Trauma. Retained placenta. Retained products. Following APH. Uterine inversion.

Question 17

What are the causes of PPH following c/s?

Answer 17

Atony. Trauma. Placental site bleeding.

Question 18

How do you manage circulation in PPH resus?

Answer 18

IV access by 2 large bore cannulae. Send off blood samples. IV fluids. Give blood if severe. Be aware of potential coagulation disorders.

Question 19

What is the approach to PPH after vaginal delivery?

Answer 19

Is the uterus contracted?
No- is the uterus empty?
Yes- trauma
Is the uterus there? No- uterine inversion

Question 20

How do you manage uterine atony?

Answer 20

Massage uterus. Bimanual compression.
Give oxytocics (oxytocin, ergometrine, prostaglandin). Empty bladder. Aortic compression.
If ongoing bleeding- look for other causes > uterine balloon tamponade > EUA/ laparotomy

Question 21

Which patients do you need to exercise caution when giving ergo and syntometrine?

Answer 21

HPT, pre eclampsia, heart disease

Question 22

What is the management of retained placenta?

Answer 22

Ideally removed in theatre under regional anaesthesia
Not possible/ patient bleeding heavily- remove in labour ward with analgesia
Oxytocin infusion and antibiotic prophylaxis post procedure

Question 23

How is an inverted uterus diagnosed and managed?

Answer 23

Patient rapidly becomes profoundly shocked and no uterus palpated.
Try and reduce the inversion, do not remove the placenta.
If unsuccessful- hydrostatic pressure.
Last resort- surgery.

Question 24

What is performed at laparotomy in PPH?

Answer 24

Compression of the aorta
Uterine compression suture such as B-lynch suture
Uterine vessel ligation
Hysterectomy

Question 25

How is PPH prevented?

Answer 25

Routine iron supplementation in pregnancy. Anticipate (detect at risk women, have supplies available). Prevent prolonged labour. Active management of third stage. Routine postpartum and post Caesar monitoring