PPH Flashcards
Define PPH
Blood loss of 550mls or above following deliver of baby and placenta
Primary <24hours of birth
Secondary >24hour-12 weeks
Minor
500mls-1000mls
Major >1000mls
moderate 1000mls-2000mls sever 2000mls plus
Can be concealed or revealed
What are the risk factors pre-labour? X12
Placenta previa
Previous retained product or PPH (reoccurrence rate of 8-10%)
Previous caesarean section (associated with placenta previa, uterine rupture, percreta and accreta)
APH
Overdistention of the uterus (polyhydramnios, multiple pregnancy, macrosomia)
Pre-eclampsia
Maternal WT <60kg
BMI >35
Increased maternal age
Existing uterine abnormalities
HB <90 g/L at the start of labour
What are the risk factors of PPH intrapartum? X9
Induction of labour Prolonged first stage Use of oxytocin or misoprostol in labour Retained placenta Precipitate labour Operative vaginal birth Caesarean, particularly in second stage Placental abruption Pyrexia
What are the 4 T’s of PPH?
Tone 70%
Tissue 20%
Thrombin 1%
Trauma 9%
What is the main cause of PPH?
Atonic uterus 70-90%, with or without retained product
What is a prevention of PPH?
identify risk factors
active 3rd stage reduces risk of PPH by 66%
Initial sentences???
Requires prompt initiation of multiple simultaneous actions
Upon recognising a PPH what should be the first actions??
Call for help
SOAPS
Haematologist
bloodbank
What is the immediate action requires irrespective of cause?
Lie flat
high flow O2 (15L) non rebreathable mask
keep warm
OBS- MEOWs
SATS, RR, pulse, BP, Temp, capillary refill
Catheterise- empty bladder measure - urometer - fluid balance
2x IV access - urgent bloods - FBC, U&E, G&S, LFT, Xmatch 4 units
consider CVP
rub up contraction - expel clots
Fluid resuscitation:
2L of crystalloid hartmans or 0.9% sodium chloride warm
consider blood products
Xmatch ASAP otherwise
O neg - and clotting factors, cryocipitate, FFP, Platlets
What are the signs for maternal shock? and what could this suggest?
Maternal tachy 100bmp> resps 30> capillary refill 2seconds> indication of significant blood loss If syst <100 indicated 25% blood loss
What is involved in assessment?
EBL
OBs- shock
Clinical hist
4 T’s
Whats should you do to stop the bleeding manually?
Uterine massage- expel clots- bimanual compression
Apply pressure to tears/epis - repair
Retained products- manual removal if necessary
Thrombin - give blood products
What first line drugs should be given?
If third stage has been actively managed and bleeding continues repeat dose can be given
10IU of sytocinon
1 ampule sytometrine
If uterus contracts begin sytocinon infusion:
40IU syntocinon in 500mls of 0.9 sodium chloride
125mls/hr over 4hours
Consider Tranexamic acid 1g slow IV
if bleeding continues 30mins or reoccurred <24hours repeat dose
If first line drugs given yet bleeding in unrelenting what drugs should be considered?
Carboprost 250mcg up to eight doses at 15min intervals
Misoprostal 600-1000mcg sublingual or PR
What are the mechanical and surgical measures may be used to stop bleeding?
Balloon tamponade - uterine pressure and create tone Laparotomy - if abdo not open B-lynch intervention radiology uterine vessel and arterial ligation Hysterectomy - 40 per 100,000
