PPH

Question 1

What is the significance of PPH?

Answer 1

• leading cause of maternal mortality worldwide
• in the UK accounts for approx 10% of all direct maternal deaths
• also a significant cause of maternal morbidity

Question 2

How can PPH be defined?

Answer 2

• it is blood loss from the genital tract following delivery of the baby of 500mls or more or any amount which is detrimental to the woman’s condition
• primary —> 1st 24 hours
• secondary —> 24 hours - 6 weeks
• major > 1000 mls can be moderate (1000-2000mls) or severe (>2000mls)

Question 3

What is the blood flow to the uterus at term?

Answer 3

• it is approximately 1000ml of blood every minute and a fetus at term receives about 200ml/kg/minute from the placenta

Question 4

How is maternal physiology well prepared for haemorrhage?

Answer 4

• increase in blood volume
• increase in clotting factors
• living ligature action of oblique muscle fibres, as a result 30% blood volume can be lost before becomes symptomatic

Question 5

How can blood loss be underestimated in smaller women?

Answer 5

• the circulating blood volume increases in pregnancy to approximately 100ml/kg and so responses to the estimated blood loss should take the woman’s stature into account

Question 6

What are the causes of PPH?

Answer 6

• TONE —> state of uterine atony (70%)
• TRAUMA —> cervical, vaginal lacerations, uterine inversion (20%)
• TISSUE —> retained placenta, invasive placenta (10%)
• THROMBIN —> clotting disorders (1%)

Question 7

What are the predisposing factors for PPH?

Answer 7

• full bladder
• long labour
• macrosomia
• twins
• polyhydramnios
• APH
• previous PPH
• precipitate birth
• IOL or augmentation
• chorioamnionitis
• episiotomy
• instrumental/operative delivery
• mismanagement 3rd stage
• fibroids
• retained placenta
• retained products
• anaemia
• abnormal placentation
• GA
• OC
• obesity

Question 8

How can it be prevented?

Answer 8

• skin to skin contact/BF
• active management
• pronurturance plus theory
  —> birthing environment, the midwife, own views on 3rd stage

Question 9

Describe the physiology of how the uterus contracts

Answer 9

• oxytocin is secreted and released in a pulsatile manner by the posterior pituitary gland
• it has effects relevant to pronurturance on both the brain and the uterus
• in the brain oxytocin creates calm loving thoughts which translate to nurturing behaviours
• oxytocin binds to myometrial cell receptors and initiates action potentials which cause uterine contractions
• adrenaline which is released by the sympathetic nervous system in situations of fear, also bind to the same receptor sites as oxytocin
• when adrenaline is on the binding site oxytocin competes with it or in the worst case is completely blocked

Question 10

How should a PPH be managed?

Answer 10

• call for help (SOAPS) contact haematologist
  SIMULTANEOUSLY
• lie the woman flat and give high-flow oxygen
• massage uterus - expel any clots and rub up a contraction, consider biannual compression if placenta already out
• IV acces, 2x wide bore cannulae, take FBC, clotting, group and x-match 4 units
• give 2L of crystalloid (once prescribed), give through warmer and pressure bag
• deliver placenta by CCT if not already delivered and check for completeness
• maternal observations
• assess cause (TONE, TRAUMA, TISSUE, THROMBIN)
• empty bladder, catheterise and attach urometer bag
• give 10IU oxytocin IM (takes 21/2 minutes to act)
• consider further uterotonics
  —> syntometrine/ergometrine 5 IU oxytocin 500 mcg IM or slow IV
  —> 40IU syntocinon IVI
  —> tranexamic acid
  —> carboprost 250 mcg IM every 15 mins up to 8 doses
  —> misoprostol
• bimanual compression (insert one hand into the vagina and form a fit into the anterior fornix and apply pressure against the anterior wall of the uterus, with the other hand press external on the uterine fundus and compress the uterus between your hands)
• repair any perineal/vaginal/cervical tears
• document observation on MEWS chart
• continually assess blood loss
• fluid balance
• blood transfusion -> consider O- in emergency, FFP, platelets, cryoprecipitate
• documentation

Question 11

What should be done when the bleeding is managed?

Answer 11

• DVT prophylaxis
• DATIX
• document and complete any audits
• continue observations and IV syntocinon
• help facilitate breastfeeding