Post-partum hemorrhage

Question 1

Define primary postpartum hemorrhage.

Answer 1

blood loss ≥ 500 ml within 24hrs of vaginal delivery, or blood loss ≥ 1,000 ml within 24hrs of Caesarean delivery, or any amount of blood loss that disturbs maternal hemodynamic status

Question 2

What is given for prophylaxis of PPH?

Answer 2

Oxytocin 20 IU in 1L at 30 drops /min (grand multiparity)

Question 2

Give 5 causes of PPH.

Answer 2

Uterine atony, retained products of conception, vaginal/cervical laceration, uterine rupture, uterine inversion, coagulation disorders

Question 2

Give 5 risk factors for PPH.

Answer 2

• Grand multiparity
• Multiple gestation
• Severe pre-eclampsia
• Placenta abruptio
• Obesity
• Large uterine myomas
• Macrosomia
• Polyhydramnios
• Prolonged labor

Question 3

Define secondary PPH.

Answer 3

Abnormal bleeding at 24hrs to 6 weeks postnatal

Question 4

What does Active Management of Third Stage of Labour (AMTSL) include?

Answer 4

• Oxytocin 10 IU IM immediately after deliveries
• Controlled cord traction for delivery of placenta
• Uterine massage
• Regular and frequent assessment of uterine tone by palpation of fundus after delivery of placenta
• Misoprostol 600 ug administered orally (if oxytocin is not available)

Question 5

How do you diagnose PPH?

Answer 5

1. Laboratory measures: e.g., hematocrit, hemoglobin to estimate blood loss
2. Physical examination findings: e.g., lacerations, hematoma, any other visible cause of bleeding, boggy uterus
3. Speculum examination:
   Uterine inversion
   Retained placental tissue or membranes
   Puerperal hematoma
4. Ultrasound
   Used to determine the correlation between the placenta and the cervical os
   Helpful to diagnose the following:
   Uterine atony: showing, e.g., an echogenic endometrial stripe
   Abnormal placental attachment: showing, e.g., thinning of uterine myometrial wall
5. Color Doppler ultrasound: to confirm abnormal placental attachment (showing, e.g., turbulent blood flow)

Question 6

What does EMOTIVE stand for?

Answer 6

Early identification
Massage the uterus
Oxytocin
Tranexamic acid
IV fluids
Examine and escalate

Question 7

Name the 4 Ts for the causes of PPH.

Answer 7

Tone, Trauma (Tears), Tissue, Thrombin

Question 8

How is PPH managed?

Answer 8

See the guidelines for management

Question 8

What does the mnemonic HAEMOSTASIS stand for?

Answer 8

Help (call for help)
A
Etiology, ecbolics
Massage the uterus
Oxytocin
Shift patient to theatre, Suprapubic pressure
Tamponade or pack uterus
Apply compression suture
Systemic devascularization
Intervention radiology
Subtotal hysterectomy or total hysterectomy

Question 9

What a NASG?

Answer 9

The Non-pneumatic Anti-Shock Garment (NASG) is a low-cost first-aid device that limits persistent PPH. It’s a compression suit originally designed with technology from the United States National Aeronautics and Space Administration (NASA).

The NASG reduces blood flow to the uterus and treats hypovolemic shock. It can keep a woman with PPH alive for up to 48 hours. Without it, she may bleed out within 30 minutes. This buys critical time to transfer a patient to healthcare and provide treatment.