PPH

Question 1

what is the definition of a PPH

Answer 1

Blood loss 500ml and continuing or blood loss that causes a woman to become symptomatic.

Question 2

What are the clinical signs and symptoms

Answer 2

• general unwell feeling, lightheaded, faint
• pallor, cold peripheries, goosebumps
• HYPOtension and tachycardia (or bradycardia)
• agitation or confusion

Question 3

what is the incidence of PPH

Answer 3

1-5% of all births

Question 4

Antenatal risk factors for PPH:

Answer 4

• previous PPH
• LGA baby (>4000g)
• hypertensive disorders
• obesity
• bleeding disorders
• placenta praevia / acreta

Question 5

intrapartum risk factors for PPH:

Answer 5

• induction of labour
• prolonged 1st and or 2nd stage
• precipitate labour
• instrumental delivery
• caesarean section
• lacerations / genital tract trauma

Question 6

four causes of PPH

Answer 6

1. tone
2. tissue
3. trauma
4. thrombin

Question 7

initial management:

Answer 7

• declare emergency
• call for help
• PPH box
• delivery placenta if not already
• fundal massage
• expel clots
• give initial uterotonic (oxytocin 10iu I.M. or 5iu IV).
• baby to breast
• empty bladder - catheterise

Question 8

management if bleeding continues

Answer 8

• call 7777
• have someone checking vital signs
• have someone gain IV access - 2x 16g cannulas
• take bloods and send to lab
• continue fundal massage / expelling clots
• give another uterotonic (could give oxytocin again or syntometrine)
• start an oxytocin infusion of 40iu in 500ml bag of saline @ 125ml/hr
• examine if placenta complete
• assess perineum and genital tract from trauma

Question 9

which bloods should be taken?

Answer 9

• full blood count
• group and cross match
• coags and fibrinogen

Question 10

when should syntometrine not be given?

Answer 10

in women with hypertensive disorders

Question 11

what to do if the woman is becoming haemodynamically unstable?

Answer 11

• lie her flat
• administer oxygen
• fluid replacement - 2-3 litres of crystalloid infusion (saline or hartmanns)
• transfuse RBC if cross matched blood available - otherwise consider O-
• if haemorrhage exceeds 2000ml - activate the massive transfusion protocol

Question 12

what other measures or drugs can be given alongside uterotonics?

Answer 12

• tranexamic acid (1gram in 10 ml) I.V. slow push over 10 min or infusion in 100ml bag @600ml/hr
• control bleeding from genital tract trauma
• bimanual compression

Question 13

if uterine atony continues, what other medication could be given?

Answer 13

• carboprost 250mcg I.M. or intramyometrially can be given up to 8 doses 15 min aprt
• misoprostil 800mcg PR once only