Bleeding during delivery

Question 1

What are some causes of intrapartum bleeding? (2nd stage of labour)

Answer 1

Placenta previa (low laying placenta)
Abruption of placenta
Vasa previa - Fetal vessels within amniotic membranes pass over the cervix.
Uterine rupture

Question 2

What are some causes of placental bleeding? (3rd stage of labour)

Answer 2

Problem in separation of placenta (Accreta syndromes)
Uterine inversion
Uterine rupture
Uterine atony

Question 3

What are the 4 signs of Placental separation?

Answer 3

Rising of the uterus in abdominal cavity
Sudden gush of blood
lengthening of the umbilical cord
Globular and firmer fundus

Question 4

What does significant bleeding after placental separation indicate? Treatment?

Answer 4

Partial separation of the placenta.

Treatment is Manual placental removal. Gentle sweep fingers side to side under the placenta, and then remove.

Question 5

What is uterine atony? How to prevent the bleeding?

Answer 5

Failure of uterus to contract significantly -> does not arrest bleeding.
Massage the fundus to stop the bleeding, if persists -> oxytocin (uterine contractions)

Question 6

What are the risk factors of uterine atony?

Answer 6

Overdistended uterus - more likely to result in hypotonia
caused by multiple gestation, large foetus, polyhydramnios

Primiparity

Question 7

What is uterine inversion? What causes it?

Answer 7

Uterus turns inside out, protrudes outside vagina. Due to too much pressure placed on uterus before signs of separation (placenta still firmly attached)

Question 8

Management of uterine inversion?

Answer 8

Uterine relaxation agents - place uterus back into normal position and then apply uterine contracting agents to prevent reinversion.

Question 9

What is the placenta accreta spectrum?

Answer 9

1. Placenta Accreta - chorionic villi attach to the myometrium instead of the decidua basalis.
2. Placenta Increta - chorionic villi penetrate into the myometrium
3. Placenta Percreta - chorionic villi penetrate through myometrium, to perimetrium. Sometimes invades adjacent bladder wall.

Question 10

Clinical picture of placenta acreta spectrum?

Answer 10

Due to abnormal attachment - increased risk of heavy bleeding at time of placental delivery.

Question 11

Treatment of placenta accreta spectrum?

Answer 11

If small placentation - manual separation

If large placentation - total hysterectomy (only option due to increased risk of hemorrhage)

Question 12

Cause of placental accreta spectrum?

Answer 12

Previous uterine surgery leading to scaring -> thin endometrium - healthy decidua not able to form.

Question 13

What is the maternal death triad, responsible for 75% of deaths?

Answer 13

Obstetrical hemorrhage
Infections
Hypertension (eclampsia, pre-eclampsia)