PPH

Question 1

What are the risk factors for developing PPH and how can they be minimised?

Answer 1

• Risk factors may antenatally or intrapartum;
• care plans modified as & when risk factors arise.
• risk factors for PPH when counselling women about place of delivery.
• known risk factors for PPH : delivered in hospital with a bloodbank on site.

Question 2

How risk factors for developing PPH can be minimised antenatally?

Answer 2

Minimising risk – treating antenatal anaemia( reduce morbidity)

Question 3

How risk factors for developing PPH can be minimised intrapartum?
Minimising risk – reducing blood loss at delivery

Answer 3

Minimising risk – reducing blood loss at delivery

1- Uterine massage is of no benefit in prophylaxis of PPH.
2- Prophylactic uterotonics should be routinely offered in MX of third stage of labour in all as reduce risk of PPH.

3- For women without risk factors for PPH delivering vaginally, oxytocin (10 iu by intramuscularinjection) is the agent of choice for prophylaxis in the third stage of labour. A higher dose ofoxytocin is unlikely to be beneficial.
4- For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) shouldbe used to encourage contraction of the uterus and to decrease blood loss.
5- Ergometrine–oxytocin may be used in the absence of hypertension in women at increased riskof haemorrhage as it reduces the risk of minor PPH (500–1000 ml).
6- For women at increased risk of haemorrhage, it is possible that a combination of preventativemeasures might be superior to syntocinon alone to prevent PPH.
7- Clinicians should consider the use of intravenous tranexamic acid (0.5–1.0 g), in addition to oxytocin,at caesarean section to reduce blood loss in women at increased risk of PPH

Question 4

Identification of the severity of haemorrhage

Answer 4

• Clinicians should be aware that the visual estimation of peripartum blood loss is inaccurate
• clinical signs and symptoms should be included in the assessment of PPH.

Question 5

Communication with the woman

Answer 5

Communication with the patient and her birthing partner is important, and clear information ofwhat is happening should be given from the outset.

Question 6

Who should be informed when the woman prese nts with PPH?

Answer 6

• Relevant staff with an appropriate level of expertise should be alerted of PPH. [
• The midwife in charge and the first-line obstetric and anaesthetic staff should be alerted whenwomen present with minor PPH (blood loss 500–1000 ml) without clinical shock
• A multidisciplinary team involving senior members of staff should be summoned to attend towomen with major PPH (blood loss of more than 1000 ml) and ongoing bleeding or clinical shock

Question 7

Measures for minor PPH (blood loss 500–1000 ml) without clinical shock:

Answer 7

• IV access (one 14-gauge cannula)
• urgent venepuncture (20 ml) for:
  – group and screen
  – full blood count
  – coagulation screen, including fibrinogen
• pulse, respiratory rate and blood pressure recording every 15 minutes
• commence warmed crystalloid infusion

Question 8

Measures formajor PPH

Full protocol formajor PPH (blood loss greater than 1000 ml) and continuing to bleed orclinical shock

Answer 8

• A and B – assess airway and breathing
• C – evaluate circulation
• position the patient flat
• keep woman warm using appropriate available measures
• transfuse blood as soon as possible, if clinically required
• until blood is available, infuse up to 3.5 l of warmed clear fluids, initially 2 l of warmedisotonic crystalloid. Further fluid resuscitation can continue with additional isotoniccrystalloid or colloid (succinylated gelatin). Hydroxyethyl starch should not be used.
• the best equipment available should be used to achieve rapid warmed infusion of fluids
• special blood filters should not be used, as they slow infusions

Question 9

Blood transfusion

Answer 9

There are no firm criteria for initiating red cell transfusion. The decision to provide bloodtransfusion should be based on both clinical and haematological assessment. [New 2016]

Question 10

Selection of red cell units for transfusion

Answer 10

• Major obstetric haemorrhage protocols must include the provision of emergency blood withimmediate issue of group O, rhesus D (RhD)-negative and K-negative units, with a switch togroup-specific blood as soon as feasible.
• If clinically significant red cell antibodies are present, close liaison with the transfusion laboratory isessential to avoid delay in transfusion in life-threatening haemorrhage.
• All delivery units, especially small units without a blood bank on site, should maintain a supplyof group O, RhD-negative blood.
• Intraoperative cell salvage should be considered for emergency use in PPH associated withcaesarean section and with vaginal delivery.

Question 11

Transfusion of fresh frozen plasma (FFP)

Answer 11

• If no haemostatic results are available and bleeding is continuing, then, after 4 units of redblood cells, FFP should be infused at a dose of 12–15 ml/kg until haemostatic test results areknown.
• If no haemostatic tests are available, early FFP should be considered for conditions with asuspected coagulopathy, such as placental abruption or amniotic fluid embolism, or wheredetection of PPH has been delayed.
• If prothrombin time/activated partial thromboplastin time is more than 1.5 times normal andhaemorrhage is ongoing, volumes of FFP in excess of 15 ml/kg are likely to be needed tocorrect coagulopathy.
• Clinicians should be aware that these blood components must be ordered as soon as a needfor them is anticipated, as there will always be a short delay in supply because of the need forthawing. [New 2016

Question 12

Fibrinogen

Answer 12

• A plasma fibrinogen level of greater than 2 g/l should be maintained during ongoing PPH.
• Cryoprecipitate should be used for fibrinogen replacement.

Question 13

Transfusion of platelets

Answer 13

• During PPH, platelets should be transfused
• when platelet count < 75 3 109/l
• based on laboratory monitoring.

Question 14

Is there a role for antifibrinolytic drugs?

Answer 14

Consideration should be given to use of tranexamic acid in MX of PPH.

Question 15

Is there a role for recombinant factor VIIa (rFVIIa) therapy?

Answer 15

• routine use of rFVIIa is not recommended in MX of major PPH
• unless as part of a clinical trial. 

Question 16

Monitoring and investigation in major PPH: what investigations should be performed and how should women bemonitored?

Full protocol for monitoring and investigation inmajor PPH (blood loss greater than 1000 ml)and ongoing haemorrhageor clinical shock:

Answer 16

• immediate venepuncture (20 ml) for:
  – cross-match (4 units minimum)
  – full blood count
  – coagulation screen, including fibrinogen
  – renal and liver function for baseline
• monitor temperature every 15 minutes
• continuous pulse, blood pressure recording and respiratory rate (using oximeter,electrocardiogram and automated blood pressure recording)
• Foley catheter to monitor urine output
• two peripheral cannulae, 14 gauge
• consider arterial line monitoring (once appropriately experienced staff available for insertion)
• consider transfer to intensive therapy unit once the bleeding is controlled or monitoring athigh dependency unit on delivery suite, if appropriate
• recording of parameters on a modified early obstetric warning score (MEOWS) chart (seeAppendix IV)
• acting and escalating promptly when abnormal scores from a MEOWS chart are observed
• documentation of fluid balance, blood, blood products and procedures

Question 17

What is the role of the anaesthetist in the management of PPH?

Answer 17

• multidisciplinary approach:
• anaesthetist plays a crucial role in maintaining haemodynamic stability &, if necessary, in determining & administering most appropriate method of anaesthesia.

Question 18

What methods should be employed to arrest the bleeding?

Answer 18

Clinicians should be prepared to use combination of pharmacological, mechanical and surgical methods to arrest PPH.
- These methods should be directed towards the causative factor.

Question 19

What pharmacological and mechanical strategies can be used?

Answer 19

• uterine atony cause of bleeding sequence of mechanical and pharmacological measures should be instituted in turn until bleeding stops.

Question 20

What surgical treatments can be employed to arrest the bleeding?

Answer 20

• If pharmacological measures fail to control the haemorrhage, surgical interventions should beinitiated sooner rather than later.
• Intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage.
• Conservative surgical interventions may be attempted as second line, depending on clinical circumstances and available expertise.
• It is recommended that a laminated diagram of the brace suture technique be kept in theatre.
• Resort to hysterectomy sooner rather than later (especially in cases of placenta accreta oruterine rupture).
• Ideally and when feasible, a second experienced clinician should be involved in the decision forhysterectomy.

Question 21

How should secondary PPH be managed?.

Answer 21

• In women presenting with secondary PPH, an assessment of vaginal microbiology should beperformed (high vaginal and endocervical swabs) and appropriate use of antimicrobial therapyshould be initiated when endometritis is suspected.
• A pelvic ultrasound may help to exclude the presence of retained products of conception,although the diagnosis of retained products is unreliable.
• Surgical evacuation of retained placental tissue should be undertaken or supervised by anexperienced clinician

Question 22

Training and preparation: what measures can be taken to ensure optimal management of PPH?

Answer 22

• Every maternity unit: multidisciplinary protocol for MX
• All staff in maternity care: training in MX of obstetric emergencies, including PPH.
• Training for PPH should be multiprofessional and include team rehearsals.
• All cases of PPH involving a blood loss of greater than 1500 ml should be the subject of formal clinical incident review.

Question 23

Documentation

Answer 23

Accurate documentation essential.

Question 24

Debriefing, Whom and where and what, offer

Answer 24

• discuss events surrounding obstetric haemorrhage
• woman (possibly with her birthing partner/s)
• mutually convenient time.