Haemorrhage

Question 1

Define Postpartum Haemorrhage (PPH)

Answer 1

Significant blood loss after birth, including vaginal bleeding up to 12 weeks postpartum.

Question 2

How much blood loss is ‘significant’ after normal vaginal delivery (NVD)?

Answer 2

> 500mL

Question 3

How much blood loss is ‘significant’ after LSCS?

Answer 3

> 1000mL

Question 4

Define moderate PPH.

Answer 4

500-1000mL EBL

Question 5

Define moderate PPH.

Answer 5

1000-2000mL EBL

Question 6

Define severe PPH.

Answer 6

> 2000mL EBL

Question 7

What maternal observations may suggest PPH if the bleeding is internal?

Answer 7

Increased HR
Decreased BP
Reduced O2 saturations

Question 8

What is a primary PPH?

Answer 8

Occurring within 24 hours of labour

Question 9

What is secondary PPH?

Answer 9

Occurring between 24 hours postpartum and 12/52 postpartum

Question 10

What are the 4 T’s for PPH?

Answer 10

Tone, Trauma, Tissue, Thrombin

Question 11

What is uterine atony (tone)?

Answer 11

A spongy, soft, boggy uterus that produces a slow and steady blood loss. This is due to myometrium inactivity and lack of endometrial artery clamping.

Question 12

What can cause uterine atony?

Answer 12

1. Repeated distention (multiparous, twins, triplets)
2. Muscle fatigue (after delivery)
3. Unable to empty bladder (pushes against the uterus)
4. Obstetric medications (anaesthetics, magnesium sulfate, nifedipine, terbutaline)

Question 13

List the potential treatments of uterine atony?

Answer 13

1. Fundal massage (encourages the myometrium to contract)
2. Urination or catheterisation to relieve the pressure on the uterus
3. Medication (tranexamic acid)
4. Surgery (repair, balloon, B.Lynch suture, uterine artery ligation, hysterectomy)

Question 14

What can cause genital damage?

Answer 14

1. LSCS incision
2. Baby causing damage coming down the vaginal canal
3. Medical instrument damage (forceps, ventouse, episiotomy)

Question 15

How does trauma PPH need to be dealt with?

Answer 15

As an emergency, bleeding must be prevented immediately via pressure on the site of bleeding and stitching lacerations.

Question 16

What is a haematoma?

Answer 16

A mass/collection of blood.

Question 17

Define placenta accreta.

Answer 17

The placental tissue invades the endometrial and myometrial tissue. This means it is hard to detach from the uterus. This can cause excessive bleeding (PPH).

Question 18

What can cause placental retention?

Answer 18

• Placenta accreta
• Placenta praevia
• Too much cord traction

Question 19

How do we deal with RPOC?

Answer 19

Remove them surgically

Question 20

What causes ‘Thrombin’ in PPH?

Answer 20

If mum has a blood clotting disorder

• Genetic - vWD
• Obstetric - Eclampsia, placental abruption

Question 21

What is a massive obstetric haemorrhage (MOH)?

Answer 21

Blood loss >1500mL

Question 22

What are the 10 antepartum risk factors for PPH?

Answer 22

1. Placental abruption
2. Placenta praevia
3. Multiple pregnancy
4. PET
5. GDM
6. Previous PPH
7. Ethnicity
8. Obesity (BMI >30)
9. Anaemia
10. Uterine anomalies

Question 23

What are the 8 intrapartum risk factors for PPH?

Answer 23

1. LSCS (emergency>elective)
2. IoL
3. RPOC
4. Episiotomy
5. Instrumental delivery
6. Prolonged labour
7. Macrocosmic baby
8. Pyrexia in labour

Question 24

What injection can be given to a woman during PPH?

Answer 24

Tranexamic acid

Question 25

What is a bimanual compression?

Answer 25

One hand on the anterior abdominal wall, the other in the vagina. Compression on either side of the uterus (outside on the fundus, inside on the cervix).