Prolapse and PPH Flashcards
What is a Cord Prolapse?
The umbilical cord slips into the birth canal ahead of the baby or alongside the presenting part. Usually seen in abnormal lie’s or positions of baby that allow space for cord to drop eg breech
Why a Cord Prolapse is a Promblem
- When the cord get cold, dry and touched it will spasm
- It will constrict blood flow to the baby causing asphyxia and hypoxic ischaemia causing brain damage or death
- It can also be compressed by a part of the baby against a wall which achieves the same thing
- Don’t use wet pad as that can make the cord cold and spasm
Transfer of a Cord Prolapse
- Transfer immediately
- Pre alert to an obstetrics unit as they need obstetric surgeons
- Reassess for imminent birth continually
- Transfer in the exaggerated sims positioning - bum in the air on side, with pillow propping up bottom
- If lone clinician
Managment of Cord Prolapse
- Put the mother into the knee chest position - this pushes the weight of the baby downwards away from compressing the cord
- Put cord onto DRY sanitary pad onto knickers, put them on and then leave
- Walk straight to the ambulance
- Don’t delay to cannulate if possible
- Once on the ambulance move into the exaggerated sim position by elevating the hips on one side while mum is lying flat, face down
- If attending solo, position the women in the knee/chest position while awaiting backup
What is Classified as a PPH?
Lost 500ml is classified as PPH. Is either primary or secondary
Primary - within 24 hours of birth
Secondary - from 24 hours to 6 weeks
Pathophysiology of a Primary PPH
The uterine muscle needs to contract post birth in order to close off placental arteries. If the uterine muscle lacks tone the placental bed will continue to bleed. 70% of PPH is from this.
Pathophysiology of a Secondary PPH
Retained products like placenta, membranes or blots are the likely cause of secondary PPH; this can also lead to infection
Causes of PPH - The 4 T’s
- Tone (poor uterine) - 70%
- Trauma - 20%
- Tissue (retained product eg clots or placenta therefore doesn’t contract properly, also probably septic - 10%
- Thrombin (keep bleeding, poor coagulopathy eg haemophilia) - 1%
PPH Alogirthm
- Request backup, lie flat and put on high flow
- Uterine massage
- Uterotonic drugs
- Bilateral cannulas - large bore
- Consider 1-2L fluids
- Give TXA 1g over 10 minutes
- Transfer to obstetric unit as complete ideal other than
Fundus Massage
- Can be above the umbilicus - this will feel like a boggy mass and not hard
- Can be below the umbilicus - usually like a cricket ball and this would have tone
- Is a painful procedure
- Karate chop into the abdomen and rotate quite deep
- Should feel the uterus get harder and lower, likelihood is the uterus will relax again so should keep hand there to feel it and restart massage
- If not massively concerned, breastfeeding can promote PPH reducing
Things to Note about Bimanual Compression
- You don’t really want to be doing this as a paramedic as once in situ the clinician is stuck like this until wheeled into surgery
- Last resort; failed massage, drugs and fluids but still bleeding out with reducing GCS and showing signs of shock
- Realistically you need to be in the ambulance before performing this manoeuvre
Procedure of How to do Bimanual Compression
- Make a pringle hand to insert
- Then make a fist and push hard up against the cervical opening as high up as possible
- Then with other hand push from the abdomen to press in opposite direction to fist
- Can move fist if not working to alter position of pressure
Do Nots (Placenta)
Do not pull the cord because you can invert the uterus which will cause the mum to go into massive shock
