Obs: L&D - PPH

Question 1

what is PPH (postpartum haemorrhage)

Answer 1

bleeding after delivery of the baby and placenta

Question 2

what quantifies a PPH?

Answer 2

500ml after vaginal delivery

1000ml after caesarean section

Question 3

whats the difference between primary and secondary PPH?

Answer 3

primary = bleeding within 24 hours

secondary = bleeding from 24 hours to 12 weeks after birth

Question 4

how are PPH classified on blood loss volumes?

Answer 4

minor PPH - under 1000ml

major - over 1000ml (moderate = 1000-2000ml, severe = over 2000ml)

Question 5

what are the causes for PPH? (4 Ts)

Answer 5

TONE - uterine atony, most common cause

TRAUMA - perineal tear

TISSUE - retained placenta

THROMBIN - bleeding disorder

Question 6

what are some risk factors for PPH?

Answer 6

• Previous PPH
• Multiple pregnancy
• Obesity
• Large baby
• Failure to progress in the second stage of labour
• Prolonged third stage
• Pre-eclampsia
• Placenta accreta
• Retained placenta
• Instrumental delivery
• General anaesthesia
• Episiotomy or perineal tear

Question 7

what are some measures that can be taken to reduce the risk and consequences of PPH

Answer 7

treat anaemia

giving birth with empty bladder (full bladder reduces uterine contraction)

active management of third stage

IV tranexamic acid

Question 8

what is the initial management of a patient with a PPH

Answer 8

• Resuscitation with an ABCDE approach
• Lie the woman flat, keep her warm and communicate with her and the partner
• Insert two large-bore cannulas
• Bloods for FBC, U&E and clotting screen
• Group and cross match 4 units
• Warmed IV fluid and blood resuscitation as required
• Oxygen (regardless of saturations)
• Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

in severe cases will need to activate MHP - rapid access to 4 units of crossmatched or O negative blood

Question 9

what are the 3 approaches to stopping the bleeding with a PPH

Answer 9

mechanical

medical

surgical

Question 10

what are the mechanical options for stopping a PPH?

Answer 10

rubbing the uterus through the abdomen to stimulate uterine contraction

catheterisation as bladder distention prevents uterus contracting

Question 11

what are some medical treatment options for stopping bleeding from a PPH?

Answer 11

• Oxytocin - slow injection followed by continuous infusion
• Ergometrine (IV or IM) stimulates smooth muscle contraction (contraindicated in hypertension)
• Carboprost (IM) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
• Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
• Tranexamic acid (IV) is an antifibrinolytic that reduces bleeding

Question 12

what are the surgical options for treating a PPH?

Answer 12

• Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
• B-Lynch suture – putting a suture around the uterus to compress it
• Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
• Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Question 13

what is the most likely cause of secondary PPH?

Answer 13

retained products of conception or infection

Question 14

how is a secondary PPH investigated?

Answer 14

ultrasound for retained products of conception

endocervical and high vaginal swabs for infection

Question 15

what is the management of secondary PPH

Answer 15

surgical evaluation of retained products of conception

antibiotics for infection