Flashcards in Postpartum hemorrhage Deck (44):
1
Definition for vaginal and C/S
More than 500ml vaginal and more than 1l c/s
2
Incidence
5-15%
3
Etiology 4Ts
Tone
Tissue
Trauma
Thrombin
4
Etiology of secondary PPH and what is the definition
After 24 hours
Retained products
Endometritis
Sub-involution of uterus
5
Labour causes of atonic uterus
prolonged, precipitous, induced, augmented
6
Overall causes of atonic uterus
Labour
Uterus
Placenta
Maternal
Pain releif
7
Uterine causes of atony
Chorioamnionitis
Overdistension
8
Causes of overdistended uterus
Multiples
Polyhydramnios
Macrosomia
Fibroids
9
Placenta causes of atony
Placenta previa
Placental abruption
10
Maternal factors associated with atony
Grandparity
Gestational HTN
Obesity
11
Tissue factors (3)
Retained products
Abnormal placenta
Blood clots
12
Trauma causes
Laceration
Episiotomy
Hematoma
Uterine rupture
Uterine inversion
13
Thrombin causes
Maternal blood disorders- VWD, TTP, ITP, DIC, pre-eclampsia HELLP
Blood thinners
14
Most common cause of PPH
Atonic uterus
15
Antenatal risk factors (11)
>35 years
Asian
Obesity
Grand multi
Uterine abnormalities
Blood disorders
Previous PPH
Anemia
16
Intrapartum risk factors
Prolonged
Precipituous
Chorioamnionitis
Oxytocin use
AFE/DIC
Uterine inversion
Genital tract trauma
AVB
CS
17
Why is a CS more likely to have PPH in some circumstances
Due to the reason for a cesarean often being an emergency
18
Post natal risk factors (4)
Retained products
AFE/DIC
Full bladder not allowing uterus to contract
Drug induced hypotonia
19
Drugs causing hypotonia used in labour
Anaesthetic
Magnesium sulphate
20
Prevention- antenatal, intrapartum and post-partum
Antepartum->Identify risk factors early, document Mx plan. Refer to specialists as required
Intrapartum->manage high risk->IV access, GH, Xmatch, have synto infusion ready
Active management of third and fourth stage
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Possible complication
Hypovolemic shock
AKI
ARDS
DIC
Sheehans syndrome
Hepatic failure
22
Management when high risk and refusal of blood products
Identify placental site
Optimise pre-birth Hb
Active management third stage labour
Identify acceptable resuscitation fluid manageemnt
Consider pharmacological, mechanical and surgical procedures to avert use of banked blood
Folic acid
Vitamine B12
Discuss AHD
Alternative/salvage therapy
Discuss risks of uterin atonia with delay in stages 1 and 2 and corrective treatment such as augmentation with oxytocin
23
Intrapartum management when high risk
Episiotomy if required
Active management third stage
IV access
FBC, GH, xmatch
BC if suspect chorioamnionitis
IV fluids, IV antibiotics if infection
Call for senior if require cesaerean
24
Active management of third stage
IM oxytocin 10 IU
Syntometrine (CI in hypertension)
Suprapubic counterpressure
Controlled cord traction
Cord clamping
25
When should suprapubic counterpressure be applied
Prior to controlled cord traction
26
Post natal risk management when risk factors
Routine care
Oxytocin infusion post birth
1/4 hourly observation for 1 hour
Maintain IV access for 24 hours
Early recognition of puerperal hematoma
27
When to suspect puerperal hematoma
Unable to ID common causes of PPH
Excessive or persistent pain
Hypovolemic shock disproportionate to revealed blood loss
Pelvic pressure
Urinary retention
28
How to manage hematoma
Resuscitate
Vaginal and PR exam to determine site and extent
?Transfer to OT for clot evacuation, primary repaire or tamponade of vessels
29
Management of PPH resus and assess
Assess blood loss
Adress woman's concerns
Lie flat, keep warm
DRABCS- call for help
Non-rebreather 02 15L
2 X 14-16 guage cannulas- send urgent FBC, GH, Xmatch, coags, UEC, Ca2+, lactate
IV1: fluid and blood component resuscitation->Avoid excess crystalloid, give 2-3L
Transfuse 2U RBCs
IV2: drug therapies
Insert IDC
Assess/record vitals every 5 minutes and temp every 15 minutes
Treat the cause
30
Treat the cause outline->questions to ask
Placenta out and complete?
Fundus firm?
Genital tract intact?
Blood clotting?
Assess for unknown
31
Unknown causes of PPH
Uterine rupture
Inversion
Puerperal hematoma
AFE, Subcapsular liver rupture
32
Management when placenta not out or incomplete
Do not massage fundus
Ensure third stage oxytocin given
Apply CCT and attempt delivery
Post delivery check if complete
Massage fundus and assess tone
Transfer to OT if needed
33
Indications to transfer to OT for tissue issue
Placenta adherent/trapped
Cotelydon + membranes missing
34
Management of atonic uterus (9)
Massage fundus
Ensure 3rd stage oxytocin given
Expel clots
Empty bladder
IV oxytocin 5IU slowly
IV/IM ergometrine 250 micrograms
Oxytocin infusion 40IU/1L crystallois @ 125-250ml/hr
PR misoprostol 800-1000mcg
Administer second line drugs if required
35
What are the second line drugs for uterus atony
Intramyometrial PGF2a (Dinoprost)
36
Management of genital tract trauma
Identify/inspect cervix, vagina, perineum
Clamp obvious bleeders
Repair
T/F to OT if indicated
37
When to transfer to OT with genital tract trauma
Cannot see/repair injury
38
Management for blood clotting disorder
Urgent FBC, caugs, eLFTs, ABG
Monitor 30-60 minutely FBC, coags, Ca, ABG
Do not delay treatment waiting for blood results
Activate MTP
39
Outline MTP
RBC, FFP, Platelets
Cryoprecipitate if Fibrinogen
40
Two things to avoid in blood clotting abnormality and MTP
Hypothermia
Acidosis
41
Management when bleeding not controlled
Bimanual compression
Transfer to OT->lay flat, oxygen
Consider criteria for MTP activation
42
OT interventions based on cause
Tissue->manual remove +/- currette
Tone-> IU balloon tamponade, angiographic embolisation, laparotomy with BiLynch compression suture/uterin artery ligation/hysterectomy
Trauma-> anaesthetic, exposure, inspect, assess uterus intact, repair
Thrombin-> angiographic embolisation, uterine artery ligation, hysterectomy
Unknown->EUA
43
Management once bleeding controlled
Monitor->vitals, fundal tone, vaginal blood loss, Hb
Promote bonding
Transfer as needed
Document
Psychological support and debriefing
Treat anemia
VTE prophylaxis
Monitor for DVT/PE
Educate on self care
Advise re followup
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