Postpartum haemorrhage Flashcards
Definition
Bleeding after delivery of the baby and placenta. It is the most common cause of significant obstetric haemorrhage, and a potential cause of maternal death
To be classed as PPH, there needes to be a loss of
500ml after a vaginal delivery
1000ml after a caesarean section
Minor PPH
< 1000ml blood loss
Major PPH
> 1000ml blood loss
Major PPH further sub-classification
- Moderate PPH – 1000 – 2000ml blood loss
- Severe PPH – over 2000ml blood loss
Primary PPH
Bleeding within 24 hours of birth
Secondary PPH
From 24 hours to 12 weeks after birth
Causes
T – Tone (uterine atony) = MC
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
Risk factors
- Previous PPH
- Multiple pregnancy
- Obesity
- Large baby
- Failure to progress in the second stage of labour
- Prolonged third stage
- Pre-eclampsia
- Placenta accreta
- Retained placenta
- Instrumental delivery
- General anaesthesia
- Episiotomy or perineal tear
Preventative measures
- Treating anaemia during the antenatal period
- Giving birth with an empty bladder (a full bladder reduces uterine contraction)
- Active management of the 3rd stage (IM oxytocin in the 3rd stage)
- IV tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
Management
- Resus: ABCDE
- Lie women flat - keep her warm
- Insert two large-bore cannulas
- Bloods for FBC, U+Es and clotting screen
- Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Oxygen (regardless of sats)
- Fresh frozen plasma used where there is clotting abnormalities or after 4 units of blood transfusion.
Major haemorrhage protocol
4 units of crossmatched or O negative blood.
Mechanical treatment to stop bleeding
- Rubbing the uterus through the abdomen to stimulate a uterine contraction (referred to as “rubbing up the fundus”)
- Catheterisation (bladder distention prevents uterus contractions)
Medical treatment
- Oxytocin (slow injection followed by continuous infusion)
- Ergometrine (IV or IM) stimulates smooth muscle contraction (CI in HTN)
- Carboprost (IM) = prostaglandin analogue and stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual) = prostaglandin analogue and stimulates uterine contraction
- Tranexamic acid (IV) is an antifibrinolytic that reduces bleeding
How is IV oxytocin given
40 units in 500 mls
