PPH Flashcards
What is a PPH?
Blood loss over 500ml following delivery
What are the categories of a PPH? (RCOG, 2016)
Minor = 500-1000ml Major = >1000ml (moderate) or >2000ml (severe)
What is the difference between a primary and secondary PPH?
Primary = first 24 hours Secondary = 24 hours - 6 weeks
How many deliveries does a PPH affect?
5-10%
What recommendations did the RCOG give for how to reduce the risk of PPH?
- Active management of 3rd stage
- Oxytocin
- Multi-professional management
What are the historical risk factors for PPH?
- Previous PPH
- Grand multiparity/ nulliparity
- Obesity
- Asian ethnicity
What are the antenatal risk factors for PPH?
Mother: - Hb <8.5 or Plt <100 at labour onset - BMI >35 - Age >35 - APH Uterus: - Over distension (poly/ multiples/ macrosomia) - Uterine abnormalities - Abnormal placentation - Fibroids
What are the intrapartum risk factors for PPH?
- Prolonged 1st/2nd/3rd stages
- IOL/ oxytocin
- Episiotomy
- Precipitate labour/ delivery
- Instrumental/ CS
- Shoulder dystocia
What do NICE (2014) recommend regarding PPH?
- Women with risk factors for PPH should be advised to give birth in an obstetric unit
- Women with PPH risk factors should have them highlighted in her notes with a care plan
- The unit should have strategies in place to respond quickly and appropriately to a PPH
What are the main complications of PPH?
- Severe anaemia
- Pituitary infarction
- Coagulopathies
- Renal damage
- Coma/ death
What is Coagulopathy?
A blood disorder that prevents the blood from clotting
What are some ways in which PPH can be prevented?
- Treat anaemia in pregnancy
- Avoid routine episiotomy
- Active management of 3rd stage
- Close obs post delivery
What are the 4 causes of PPH?
- Tone
- Trauma
- Tissue
- Thrombin
How should poor tone be managed?
- Rub up a contraction
- Bimanual compression
- Empty bladder (indwelling catheter)
How should trauma be managed?
- Check for tears/ episiotomy
- Assess difficulty and choose appropriate practitioner
- Analgesia
- Suture when able
What other 3 things does ‘trauma’ cover?
- Inverted uterus
- Ruptured uterus
- Haematomas
How should tissue problems be managed?
- Deliver placenta (manual removal if needed)
- Check placenta for retained products
How should thrombin problems be managed?
- Blood clotting on floor?
- Check clotting in blood results
- Medical history?
- Require platelets?
- Liaise with cons. Haematologist
What is the first line of drugs used to treat PPH?
- Syntometrine 1ml IM
or - Syntocinon 10iu IM
In what situation would Syntocinon be preferred to Syntometrine?
If the woman is hypertensive
What must all women who are having a CS have antenatally?
USS to confirm placental site
What are the signs of placental separation?
- Cord lengthening
- Trickle of PV blood
What other drugs are used if Synto doesn’t work?
- Repeat Syntometrine (1ml)
- Syntocinon infusion (40iu in 500ml saline at 125ml/hr)
- Haemabate (carboprost) (250mcg IM every 15 mins up to 8 doses)
- Misoprostol (800mcg PR)
What are the advantages of using Haemabate?
- Can be given IM
- Dose 250mcg
- Can be given up to 2mg (8 doses)
What are the disadvantages of using Haemabate?
- Must not be given IV
- Can cause nausea, dizziness, flushing, headache
- Caution with hypertension, cardiac disorders, pulmonary disease and asthma
How does Misoprostol work?
Induces uterine contractions
What additional drug can be used?
Tranexamic acid
What additional management is required for a severe PPH?
- CVP line and monitoring
- Early transfer to theatre
- Balloon tamponade
- B lynch suture/ embolise uterine vessels/ hysterectomy if required
What is an inverted uterus?
The passage of the fundus through the cervix (partial or complete)
What are some signs of an inverted uterus?
- Uterus may be seen outside vagina
- Uterus palpated lower than usual
- Shock disproportionate to blood loss
How should an inverted uterus be treated?
- Call for help
- Manually replace uterus
- Monitor ABC
- Treat vasovagal shock
What are the additional measures if the manual replacement of an inverted uterus is unsuccessful?
- Tocolysis
- Hydrostatic measures
- Surgical replacement
What are the risk factors for uterine rupture?
- Previous uterine surgery/ trauma
- Oxytocin use for multips
- Forceps delivery
- Previous CS and oxytocin in this labour
- IOL with prostaglandins
- Cephalopelvic disproportion
What are the signs and symptoms of uterine rupture?
- Sudden change in FHR
- Abdominal pain
- Change in abdominal shape
- Palpable foetal parts
- Vaginal bleeding
- Cessation of contractions
- Maternal tachycardia
What is the treatment for uterine rupture?
Surgical repair/ Hysterectomy
How should lacerations be managed?
- Rapid identification of bleeding points
- Pressure
- Prompt repair
How should haematomas be managed?
- Require drainage
- Litigation of bleeding points
What is the definition of a retained placenta?
One that is not delivered within 30 minutes of active management
What must you NOT do with a retained placenta?
Excessive CCT
How is a retained placenta treated?
- Keep uterus well contracted
- Manual removal if placenta not delivered in 2 hours or bleeding not controlled
- Intra-umbilical oxytocin (injected into placental site to reduce rates of manual removal)
What is placenta accreta?
Morbidly adherent, infiltrating the endometrium
What is placenta increta?
Invades into the myometrium
What is placenta percreta?
Invades through the myometrium into the serosa
When is placenta accreta etc usually identified?
Not until manual removal takes place
What is the conservative management for placenta accreta etc?
Leave in situ and give antibiotics
What is the surgical management for placenta accreta etc?
Hysterectomy
What are some signs of pre-existing blood conditions?
- Watery blood loss
- No evidence of clotting
- Oozing from puncture sites
- Bruising
How should women with pre-existing blood conditions be treated?
- Treat the underlying condition
- Involve Haematologist
- Transfusion of blood if needed
What are the 5 things to consider when treating a major PPH?
- Communication
- Initial assessment
- Monitoring and investigations
- Medical treatment
- Surgical treatment
Major PPH Treatment - Communication
- Call for help
- Alert blood transfusion
- Alert consultant on call
Major PPH Treatment - Initial Assessment
- ABC - oxygen mask (15L)
- Fluid balance
- ?Blood transfusion
- Keep patient warm
Major PPH Treatment - Monitoring and Investigations
- 14 gauge cannula x 2
- FBC, coagulation, Us&Es, LFTs, X match
- ECG
- Foley catheter
- Hb bedside testing
- ?Central/ arterial lines
- Documentation
- Weight all swabs (EBL)
How many units should be cross matched?
4
Major PPH Treatment - Medical
- Rub up contractions
- Empty bladder
- Drugs
Major PPH Treatment - Surgical
- Is the uterus contracted?
- Examination under anaesthetic
- Has any clotting abnormality been corrected?
- Intrauterine balloon tamponade
- Brace suture
- Consider interventional radiology
