Post Partum Haemorrhage Flashcards
define a PPH
excessive blood loss or more than 500ml from the genital tract following the birth of the baby up to the end of the puerperium.
fall in haemocrit of 10% or more requires transfusion.
presence of absence of haemodynamic compromise or shock
outline the different types of PPH and their defining quantities
minor- 500-1000ml
major - 1000ml +
moderate (major) - 1000-2000ml
severe (major) - 2000ml +
what is a primary and secondary PPH?
primary - first 24 hours following birth
secondary - after 24 hours
what is the relationship between PPH and maternal mortality?
most common cause of maternal mortality worldwide
responsible for 30% of maternal deaths, approx 86000 a year
mortality from PPH is falling however rate of retained placenta and PPH is increasing in western setting
what are the causes of PPH?
TONE – state of uterine atony -70%
TRAUMA –cervical vaginal lacerations uterine inversion -20%
TISSUE- retained placenta invasive placenta – 10%
THROMBIN-clotting disorders -1%
what is the blood flow to the uterus at term?
450-700mls/min
How does tone effect a PPH
contraction of the myometrium is the primary mechanism by which the placenta separates and haemostats is achieved as blood vessels are constricted.
if this does not occur as a result of the retained placenta, membranes of myometrial fatigue a PPH will occur.
risk factors for an atonic uterus.
previous PPH
over distension of uterus (polyhydramnios, LGA)
fibroids
APH
prolonged labour
drugs - uterine relaxants
retained placenta
inversion of uterus
mismanagement of 3rd stage
induced/augmentated labour
chorioamnionitis
precipitate birth
full bladder
obesity
asian/ african ethnicity
multiple pregnancy
anaemia
placenta praevia
age >40
prolonged labour
intrapartum pyrexia
placental abruption
caesarean section
what causes a ‘tissue’ PPH
placenta
clots
membranes
cotyleydon
what are the risk factors/causes for a ‘trauma’ PPH
LSCS
Episiotomy - routine episiotomy is associated with 27% increase in PPH at normal birth (carroli and mignini 2009)
instrumental delivery
internal manoeuvres eg shoulder dystocia
uterine rupture/ inversion
haematoma
what are the risk factors for a ‘thrombin’ caused PPH
coagulation defects - haemophilia
clotting disorder - von willebrands disease
prophylactic heparin within 24 hrs of birth
previous PPH
what prevention measures can be taken antenatally
risk assessment - 2/3 of women who experience PPH will have no risk factors
detect and treat anaemia RCOG 2016 women with a Hb of 90g/l or less are associated with greater blood loss at delivery
women with suspected abnormally adhered placenta have a high risk of PPH and should have a management plan documented in notes
minimising risk - intrapartum
active management of 3rd stage
Advise the woman to have active management of the third stage, because it is associated with a lower risk of a postpartum haemorrhage and/or blood transfusion. (NICE 2017)
10IU by intramuscular injection for general prophylaxis management - vaginal delivery
5IU IV for LSCS
syntometrine can be used in absence of hypertension women at increased risk of PPH
all women with known risk should be managed at a high dependency unit to access specialisst services (NICE 2014)
establish IV access
2x G&S, cross match samples (ideally do this on admission and when IV access is obtained)
active management of 3rd stage NICE 2014, RCOG
midwife’s actions for prevention of PPH
promote mobility and optimal positions to facilitate birth
nutrition and hydration
avoid interventions
promote nursing environment to increase natural oxytocin and reduce catecholamine’s
regular bladder emptying
skin to skin
early breast feeding
recognition of PPH or risks
aware of normal observations including current Hb
aware of normal blood loss in 3rd stage
can distinguish between separation bleed
recognition of when deviation from normal may occur
check placenta and membranes
careful examination of perineum
vital signs following birth, first hour care
