PPH Flashcards
Signs of placenta separation
Lengthening of the cord
Show of blood
Why not deliver placenta before it’s separated?
Might invert uterus
Vaso vagal shock, hypotension, maternal death
Oxytocics available?
Syntocinon 10 units IV
Ergometrine 0.25mg IV
Syntometrine IM
How long placenta delivered ‘naturally’?
An hour
Why active management of 3rd stage?
Reduce PPH
Technique to active management
Controlled cord traction
Do you press on uterus after syntocinon?
Nope. Let it be, watch for cord lengthening
Primary PPH?
Within 24 hours more than 500ml
Secondary PPH?
After 24 hours Up to 6 weeks, excessive amount of loss
Commonest cause of PPH?
Uterine atony (70%)
Why must uterus contract in 3rd stage
Controlled PPH via uterine muscle contraction
Causes Uterine atony?
Polyhydramnios Multiple pregnancy Macrosomia Mass - fibroids PROLONGED LABOUR
Causes of PPH via trauma 20%
episiotomy, tear in perineum
Vaginal tear
Cervical tear
Uterine rupture
Uterine rupture tends not to occur in?
Primigravid
PPH other causes
retained products
Coagolopathy
Coagulopathies around the time of delivery? 1% of time.
Preeclampsia Eclampsia DIC Placenta abruption Amniotic fluid embolism
% of PPH
70% uterine atony
20% - trauma
9% - retained products
1% - coagulapathy
Pre delivery causes of coagulopathies
Von willebrands
Throbocytopaenia
How much blood loss you need before transfusion?
1500 mL, EVEN if pulse and BP is ok.
If PPH and bleeding, given syntocinon, still bleeding what to do?
Give ergometrine
Rub the uterus
Look for tears - usu. venous pressure
Take bloods for coags
Don’t forget to put in what to help uterine contraction?
Urinary catheter to empty the bladder
If lose 1500mL, then what?
Give transfusion
Take her to theatre!!
-check for inversion, rupture, products
PGF2alpha
If after surgical exploration after losing 1500mL and still not control?
- Balloon catheter 500mL for 24 hr. ABx.
- Ligation of the uterine arteries/internal iliac arteries
- laparotomy, hysterectomy for survival
If someone has preeclampsia, how to manage PPH?
Try to avoid ergometrine
If PPH from coag disorder, how to manage?
Balloon catheter
Then give coags, FFP, platelets
Causes of secondary PPH
Infection
Retained products
secondary PPH Management?
FBE, CRP
ABx
Signs of secondary PPH Infection?
Febrile
Tender uterus
secondary PPH Speculum?
Look for discharge
Cervix likely to be open
TAKE SWABS
ABx for secondary PPH?
Penicillin
Metronidozole
If over 39 degrees: Gentamicin
All IV
secondary PPH For retained products management?
U/S
Hysteroscopy D&C
Risk of using sharp curette for retained products?
Ashermann’s syndrome
Risk of VBAC for uterine rupture?
1 in 200
Risk of VBAC of uterine rupture with augmentation?
1 in 100, up to 1 in 25
If not delivered placenta by 1 hour what to do?
Take them to theatre for manual removal
