Primary Postpartum Haemorrhage

Question 1

What are the 4 T’s associated with causes of PPH?

Answer 1

Tone (uterine atony)
Trauma (to genital structures)
Tissue (retention of placenta or membranes)
Thrombin (coagulopathy)

Question 2

What is the most common cause of PPH?

Answer 2

Uterine atony

Question 3

An empty and contracted uterus…

Answer 3

does not bleed.

Question 4

Which patients are at higher risk of PPH?

Answer 4

Multiple pregnancy
>4 pregnancies
PHx PPH
Hx APH
large baby

Question 5

Why should fundal massage be avoided until after the placenta is delivered?

Answer 5

The fundus will not become firm and contracted until after the placenta is delivered.

Question 6

Why should a firm fundus not be massaged?

Answer 6

Interferes with normal placental post-birth separation and worsens bleeding.

Question 7

Why must verbal consent be obtained for Misoprostol admin? What risks are associated?

Answer 7

Not specifically licensed for use in PPH in Australia.

Potential nausea, diarrhoea, abdo pain. May cause a C-section scar to rupture - side effects unlikely at AV dose.

Question 8

Can misoprostol and oxytocin be given to the same patient in the same period of care?

Answer 8

Yes. In the setting of PPH, if oxytocin not immediately available, then Misoprostol should be administered without delay.

Question 9

What is secondary PPH defined as, and can Misoprostol be administered for it?

Answer 9

Severe bleeding at 24hrs - 6 weeks post birth.

Consult with receiving hospital for misoprostol or oxytocin.

Question 10

What is primary PPH defined as?

Answer 10

> 500mL blood loss in first 24hrs post-birth.

Question 11

If PPH but the fundus is firm, what is the Mx?

Answer 11

1. High flow O2
2. Analgesia
3. If BP <90mmHg, consider up to 40mL Normal Saline, titrated to pt response, consult or if no consult, admin further 20ml/kg.
4. Mx any visible laceration with a dressing and pressure

Question 12

What is a firm fundus described as?

Answer 12

Palpably firm, central and compacted.

Question 13

If PPH and the fundus is not firm, what is the initial Mx?

Answer 13

1. High flow O2
2. Analgesia
3. If BP <90, up to 40mL/kg NS, titrate to response consult for further 20ml/kg
4. Ensure placenta delivered
5. Fundal massage
6. Encourage mother to empty bladder
7. Encourage baby to suckle breast

Question 14

How is fundal massage done?

Answer 14

Using a cupped hand, apply firm pressure in a circular motion until fundus firms and blood loss reduces.

Question 15

If PPH and fundus remains not firm post-fundal massage, what is the Mx?

Answer 15

Misoprostol 800mcg oral.

Request MICA for Oxytocin.

Question 16

Should paramedics attempt to delivery placenta if not delivered in PPH?

Answer 16

No, due to risk of uterine inversion.

Question 17

If fundal massage and misoprostol administered and PPH remains intractable, what is the Mx?

Answer 17

External abdominal aortic compression.

• Locate point of compression just above umbilicus and slightly to the left
• Apply downward pressure with a closed fist directly through abdominal wall
• Assess for femoral pulse, if absent - compression adequate.