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Flashcards in Postpartum Haemmorhage Deck (62)
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Define Primary Postpartum Haemorrhage

- excessive bleeding in the first 24 hours post birth
- usually considered as >500mL after vaginal birth and >1000mL after C/S
- or showing signs of haemodynamic compromise (usually >1000mL, shock, tachycardia, hypotension)


What is considered severe PPH?

>1000mL estimated blood loss


What is very severe or major PPH?

>2500mL estimated blood loss


What 4 factors make a woman more likely to show signs of haemodynamic compromise?

- gestational hypertension with proteinuria
- Anaemia
- Dehydration
- Small stature


What is Secondary Postpartum Haemorrhage?

excessive bleeding (>500mL) that occurs between 24 hours post birth and 6 weeks postnatally


What are the 4 causes of PPH?

- Tone
- Tissue
- Trauma
- Thrombin (clotting disorders)


What are the common risk factors for PPH?

- prolonged labour
- precipitate labour
- grand multiparity
- multiple pregnancy
- polyhydraminos
- macrosomia
- fibroids
- intrauterine infection
- uterine relaxing agents (MgSO4, general anaesthetic, tocolytics)
- operative birth
- cervical/vaginal lacerations
- retained placenta
- abnormal placentation
- Pre-eclampsia
- HEELP Syndrome
- placental abruption
- Bleeding disorders
- Drugs (aspirin/heparin)


What is meant by establishing IV access?

inserting 2 large bore (16G) cannulae


What blood tests are important investigations in PPH management?

- Blood group
- Antibody screen
- Full blood count
- Coagulation screening (INR, APTT, fibrinogen)


Assessment (early recognition, signs/symptoms)
Communication (Call for help, effective teamwork, support for woman and her support people)
Management (resuscitation, vital signs, IV access, monitoring blood loss, oxygen saturation

Call for help


What management is necessary for PPH where the placenta has not been born?

- call for HELP
- reassure woman
- position woman flat/lateral
- monitor vital signs (heart rate, respiration rate, blood pressure and temperature), oxygen saturation and blood loss
- consider oxygen by mask (8-12L)
- keep woman warm
- IV access
- catheter
- repeat oxytocin (another 10IU IM or IV, don't give syntometrine/ergometrine as it may prevent birth of the placenta)
- attempt to birth placenta by controlled cord traction and massage uterus once emptied
- monitor fundal tone
- check placenta for completeness
- consider tone, tissue, trauma, thrombin
- if unsuccessful portable ultrasound, prepare for manual removal of placenta, transfer to theatre


What management is needed for PPH if the placenta has been born?

- call for HELP (and appropriate equipment)
- reassure woman
- position woman flat/lateral
- massage uterus
- if no contraindications, 250mcg ergometrine IV (or 10IU oxytocin IV if hypertensive) can repeat after 2-3 minutes
- catheter
- IV access + collect blood
- monitor vital signs (heart rate, respiration rate, blood pressure and temperature), oxygen saturation and blood loss
- oxytocin infusion (40IU/1000mL IV)
- 800-1000mcg (4-5 x 200mcg tablets) misoprostol PR
OR intramyometrial injection of Prostaglandin F2a (dinoprost)
- consider oxygen by mask (8-12L)
- keep woman warm
- assess tissue (check placenta for completeness)
- assess trauma (check episiotomy or tears)
- assess thrombin (coagulation studies, are there any risk factors for clotting issues?)
- IV fluids or blood transfusion
- if bleeding continues consider bimanual compression, or aortocaval compression, transfer to theatre for examination under aesthetic and further treatment


What is the usual dose of ergometrine in the management of PPH?

- 250 micrograms
- repeat after 2-3 minutes if bleeding continues
- maximum of 4 doses (1mg)


What are the usual routes of administration for ergometrine?

IV or IM


What are the side effects of ergometrine?

- tonic uterine contraction
- nausea and vomiting
- hypertension
- rarely gangrene at site and convulsions
- cna reduce prolactin levels so potential for delayed lactogenesis


When should ergometrine not be given?

- if placenta has not been born
- severe hypertension or cardiac disease
- hypersensitivity to ergometrine


What drug is often given with ergometrine to prevent nausea/vomiting?

metoclopramide 10mg IV


What is the usual protocol for giving oxytocin in the management of PPH?

- 10IU/1ml IM or IV for active managment of 3rd stage
- may give repeat bolus of 10IU IM or IV (instead of ergometrine if placenta has not been born or if blood pressure is elevated)
- 40IU in 1000mL of sodium chloride 0.9% IV infusion at rate of 250mL/hour if placenta has been born


What is the usual dose of misoprostol in the management of PPH?

800 to 1000 micrograms PR (4-5 tablets)


What is the usual stock strength of misoprostol given PR?

200 microgram tablets


What are the side effects of misoprostol? When should it not be given?

- nausea and vomiting
- diarrhoea
- abdominal pain
- headache
- flushing
- chills
- pyrexia
- hypersensitivity to misoprostol
- may cause GI upset in infant due to transfer in breastmilk


When is misoprostol given in management of PPH?

when neither oxytocin or ergometrine are successful at stopping bleeding


Other than oxytocin, ergometrine and misoprostol, what drugs may be given in managing PPH?

- prostaglandin F2a intramyometrial injection
- syntometrine (oxytocin and ergometrine)


What are the main complications of major PPH?

- shock
- anaemia
- clotting disorders
- organ damage (particularly lung injury and renal failure)


What are the main signs of hypovolaemic shock?

- hypotension
- anxiety
- confusion
- decreased level of consciousness
- shortness of breath/ hyperventilation
- restlessness
- palpitations/ tachycardia
- chills
- pale and clammy
- thirst
- oliguria


What are the risk factors for postpartum venous thromboembolism?

- age>35
- parity>4
- clotting disorders
- dehydration
- pre-eclampsia
- prolonged labour
- immobility
- obesity
- varicose veins
- surgery
- excessive blood loss
- instrumental birth


What equipment should be in a PPH box?

- cannulation (16G, 18G, swabs, tegaderm, tape)
- pathology (23G, 21G needles, blood tubes, tourniquet, swabs, bags, slips, 10mL syringes)
- IV giving sets (standard/pump) + accessories (luer-lock connectors, additive labels, multi-adapters, 3-way adapter)
- bags of sodium chloride/hartmanns/gelofusine
- catheter (14ch foley, bag/urimeter, 10mL water for injections, 10mL syringe)
- ampules of saline/water for injections
- misoprostol 200mcg tablets

in fridge :
- oxytocin 10IU ampoules
- ergometrine 500mcg ampoules
- prostaglandin F2a (dinoprost)
- additive lables
- syringes (2mL, 5mL)
- needles (19G, 23G, 25G and spinal)


In many healthy pregnant women there are no clinical signs of shock until what volume of blood loss?

- >1000-1500ml of blood loss


Apart from the 4 Ts, what other causes may cause PPH?

- uterine rupture
- uterine inversion
- puerperal haematoma
- other causes (liver rupture, amniotic fluid embolism)


Once bleeding is controlled, what ongoing midwifery care is vital for women who have had PPH?

- monitoring vital signs, fundal tone, blood loss, haemoglobin
- promote mother/infant bonding
- transfer (to postnatal ward/ICU/HDU/tertiary facility)
- documentation
- psychological support and debriefing
- management of anaemia
- VTE prophylaxis, monitor for DVT/PE
- education about self care
- advice regarding follow up