Post Partum Haemorrhage PPH
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| Define Primary Post Partum Haemorrhage. | Blood loss >500ml within 24hrs of birth.
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| Define secondary PPH. | Blood loss >500ml from 24hrs until 6 weeks post partum.
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| When is PPH considered severe? | When blood loss exceeds 1000mls OR blood loss causes haemodynamic instability.
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| Is PPH common? | Relatively, its incidence is reported up to 18%.
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| Is PPH a top cause for maternal death in NZ? | Yes it is the 4th highest on average, 3rd highest direct cause.
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| What factors increase the risk for PPH? | Multiple pregancy, large baby,polyhydramnios, prolonged labour, PHx of APH, PPH, placentae previa or retained placents-, grande multipara, anemia, lacerations, operative delivery.
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| What are the four causes of PPH or the four T's according to greatest incidence? | Tone= atonic uterus,
Trauma= lacerations/episiotimy etc,
Tissue= retained tissue,
Thrombin= Coagulopathies.
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| Define Atony. | A lack of normal muscle tension or tone.
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| Define polyhydramnios. | Excess amniotic fluid in the amniotic sac.
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| How does one prevent PPH? | AMSTL - Active managment of third stage labour = the use of uterotonic drug soon after delivery of the anterior shoulder, controlled cord traction (40% reduction in PPH), early cord clamping and cutting -60sec.
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| To what degree does AMSTL reduce the incidence of PPH? | AMSTL reduces the incidence of PPH by up to 68%.
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| What is the most common cause of PPH? | Uterine atony.
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| An over distended uterus is often caused by? | Twins, fetal macrosomia, polyhydramnios.
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| A fatigued uterus, another cause of uterine atony is often caused by? | Prolonged labour, Amnionitis, need for augmentation.
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| What types of trauma may cause PPH? | Perineal lacerations and haematomas, vaginal/cervical lacerations, Uterine rupture/inversion/lacerations.
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| Is uterine inversion rare? | Yes, but may result in >2l of blood loss.
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| Is uterine rupture common? | No it is rare in the unscarred uterus.
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| Does uterine rupture cause massive blood loss? What is the main sign? | No it may have minimal blood loss, the main sign of uterine rupture is fetal bradycardia.
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| What are the classic signs of placental separation? | A small gush of blood, lengthening of the umbilical cord, the uterus takes a firmer globular shape, and a slight rise of the uterus in the pelvis.
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| How long does it take for most placentaes to separate from the uterine wall? | Approximately within 1 min from delivery.
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| What is the mean time for expulsion of most placentaes? | 8-9 min.
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| Is there more risk for PPH the longer the placenta takes? | Yes double the risk if it takes longer than 10 min.
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| When is a placeta considered retained? | After 30 min.
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| How common is retained placenta? | It occurs in <3% of deliveries.
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| Why are retained products such a threat to the mother? | Because it inhibits the uterus to contract.
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| What are considered retained products or obstructions? | Blood clots, placenta, membranes, uterine fibroids and the bladder
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| What are uterine fibroids? | Uterine fibroids are noncancerous growths of the uterus that often appear during your childbearing years
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| What is invasive placenta? | This is a condition involving the placenta attaching to deeply into the uterine wall, even extending through it into another organ such as the bladder.
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| Are a coagulation disorders a rare cause of PPH? | Yes.
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| When are most coaugulopathies identified? | Antenatally.
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| What are three common coaugulopathies associated with PPH? | Thrombocytopenia purpura.
Von Willebrand’s.
Haemophilia
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| What is Thrombocytopenia purpura? | the condition of having an abnormally low platelet count (thrombocytopenia) of no known cause.
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| What is von Willibrands? | A hereditary condition categorized by the lack of von Willibrand's factor, a protein essential for platelet adhesion.
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| How fast does blood circulate through the uterus? | >500ml per min.
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| Is BP a poor guide to obstetric blood loss? | Yes.
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| If you see signs of shock but no significant external blood loss and you suspect PPH where may the patient be bleeding? | Inside the uterus, it may be filled with blood - important to check the fundus.
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| What mnemonic is useful to remember when trying to identify the cause of PPH blood loss. | The four T's.
Tone.
Trauma.
Tissue.
Thrombin.
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| What is the treatment for focused perineal tears? | Direct pressure.
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| What may prevent the uterus from contracting and retracting? What do you need to check/do? | Remove clots?
Has the placenta delivered?
Is the placenta complete?
Check that the bladder is empty?
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| How do you check that the placenta has detached? | Depress the abdo and push towards the chest.
If the cord retracts into the vagina then the placenta has separated.
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| Why should you massage the uterus after the placenta is expelled? | To prevent/reduce bleeding.
To help the uterus contract/retract.
To expel clots.
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| What is the treatment for focused perineal tears? | Direct pressure.
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| What may prevent the uterus from contracting and retracting? What do you need to check/do? | Remove clots?
Has the placenta delivered?
Is the placenta complete?
Check that the bladder is empty?
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| How do you check that the placenta has detached? | Depress the abdo and push towards the chest.
If the cord retracts into the vagina then the placenta has separated.
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| Why should you massage the uterus after the placenta is expelled? | To prevent/reduce bleeding.
To help the uterus contract/retract.
To expel clots.
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| Why should you take care not to over stimulate the uterus? | It may fail to respond.
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| What should you do to express the expulsion of the placenta if it takes too long to detach? | The Brandt-Andrews manoevre.
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| What is the Brandt-Andrews manoevre? | Controlled traction on the cord with one hand.
The other hand applies suprapubic counterpressure to snare the uterus.
Continue traction but upwards along the carus as the placenta becomes visible at the introitus.
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| What is a possibility that needs to be recognized during cord traction? | The uterus can become inverted if the placenta is not separated.
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| How do you fix an inverted uterus? | 1.Grasp the protruding uterus between the thumb and the forefinger.
2. Push the uterus through the pelvis into the abdomen with steady pressure towards the umbilicus.
3. Continue with steady pressure forming a fist as the uterus is reduced.
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| Of what vascular structures does the umbulical cord consist? | 2 Arteries and 1 vein.
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| What is the management of PPH? | Contact LMC.
Empty the uterus.
Rub up the fundus.
give oxytocic if available.
Baby to nipple or nipple stimulation.
Manage tears.
Empty the bladder.
Consider bimanual compression.
IV access large bore.
Supplemental oxygen.
Fluid resus with 0.9Na
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| Define LMC | Lead maternity carer.
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| Define secondary PPH. | PPH that occurs between 24hrs and 12 weeks post partum.
Is often less severe than primary PPH.
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| What causes secondary PPH? | Retained products.
Infection.
Uterine atony.
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| What is the management of secondary PPH? | IV Fluids.
Resuscitation.
Uterine massage is not possible due to it being under the symphysis.
Load and GO.
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