PPH

Question 1

What is the definition of primary PPH?

Answer 1

Vaginal bleeding of more than 500ml in the first 24 hours after delivery

Question 2

What are the causes of primary PPH?

Answer 2

The 4Ts
Tone: uterine atony (most common)
Tissue: retained placenta or membranes
Trauma:  injury to vagina, perineum or uterine tears 
Thrombin: clotting disorders

Question 3

What is the definition of secondary PPH?

Answer 3

Vaginal bleeding of more than 500ml more than 24 hours and before 6 weeks after delivery

Question 4

What are the causes of secondary PPH?

Answer 4

Infection: endometritis

Retained products of conception

Question 5

What is uterine atony?

Answer 5

Abnormal relaxation of the uterus after delivery, usually causing bleeding

Question 6

What would you expect on examination with uterine atony?

Answer 6

A boggy, non-contracted uterus is felt above the umbilicus (should be below)

Question 7

What is the management for uterine atony?

Answer 7

DRSABC
IV access and bloods: FBE, coags, group and hold
Simple measures: insert an IDC to empty bladder, fundal massage to stimulate contractions, bimanual compression if still bleeding heavily
Medications: ergometrine, syntocinon
Surgery: examination under anaesthetic, prostaglandin injection into uterus from abdomen, Backri ballon (inflated within the uterus to provide tampanade), manual pressure on uterus, B lynch suture (a suture generated clamping of the uterus), bilateral uterine artery ligation and internal iliac artery ligation, hysterectomy (last line)

Question 8

What are Sx and signs of endometritis?

Answer 8

Foul smelling discharge
Tender uterus on examination
Fever
Tachycardia

Question 9

What Ix would you do for secondary PPH?

Answer 9

High vaginal swab
U/S
Blood cultures