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Midwifery Emergencies > PPH > Flashcards

Flashcards in PPH Deck (55)
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1
Q

What is a PPH?

A

Blood loss over 500ml following delivery

2
Q

What are the categories of a PPH? (RCOG, 2016)

A
Minor = 500-1000ml
Major = >1000ml (moderate) or >2000ml (severe)
3
Q

What is the difference between a primary and secondary PPH?

A
Primary = first 24 hours
Secondary = 24 hours - 6 weeks
4
Q

How many deliveries does a PPH affect?

A

5-10%

5
Q

What recommendations did the RCOG give for how to reduce the risk of PPH?

A
  1. Active management of 3rd stage
  2. Oxytocin
  3. Multi-professional management
6
Q

What are the historical risk factors for PPH?

A
  • Previous PPH
  • Grand multiparity/ nulliparity
  • Obesity
  • Asian ethnicity
7
Q

What are the antenatal risk factors for PPH?

A
Mother:
- Hb <8.5 or Plt <100 at labour onset
- BMI >35
- Age >35
- APH
Uterus:
- Over distension (poly/ multiples/ macrosomia)
- Uterine abnormalities
- Abnormal placentation
- Fibroids
8
Q

What are the intrapartum risk factors for PPH?

A
  • Prolonged 1st/2nd/3rd stages
  • IOL/ oxytocin
  • Episiotomy
  • Precipitate labour/ delivery
  • Instrumental/ CS
  • Shoulder dystocia
9
Q

What do NICE (2014) recommend regarding PPH?

A
  • Women with risk factors for PPH should be advised to give birth in an obstetric unit
  • Women with PPH risk factors should have them highlighted in her notes with a care plan
  • The unit should have strategies in place to respond quickly and appropriately to a PPH
10
Q

What are the main complications of PPH?

A
  • Severe anaemia
  • Pituitary infarction
  • Coagulopathies
  • Renal damage
  • Coma/ death
11
Q

What is Coagulopathy?

A

A blood disorder that prevents the blood from clotting

12
Q

What are some ways in which PPH can be prevented?

A
  • Treat anaemia in pregnancy
  • Avoid routine episiotomy
  • Active management of 3rd stage
  • Close obs post delivery
13
Q

What are the 4 causes of PPH?

A
  1. Tone
  2. Trauma
  3. Tissue
  4. Thrombin
14
Q

How should poor tone be managed?

A
  • Rub up a contraction
  • Bimanual compression
  • Empty bladder (indwelling catheter)
15
Q

How should trauma be managed?

A
  • Check for tears/ episiotomy
  • Assess difficulty and choose appropriate practitioner
  • Analgesia
  • Suture when able
16
Q

What other 3 things does ‘trauma’ cover?

A
  • Inverted uterus
  • Ruptured uterus
  • Haematomas
17
Q

How should tissue problems be managed?

A
  • Deliver placenta (manual removal if needed)

- Check placenta for retained products

18
Q

How should thrombin problems be managed?

A
  • Blood clotting on floor?
  • Check clotting in blood results
  • Medical history?
  • Require platelets?
  • Liaise with cons. Haematologist
19
Q

What is the first line of drugs used to treat PPH?

A
  • Syntometrine 1ml IM
    or
  • Syntocinon 10iu IM
20
Q

In what situation would Syntocinon be preferred to Syntometrine?

A

If the woman is hypertensive

21
Q

What must all women who are having a CS have antenatally?

A

USS to confirm placental site

22
Q

What are the signs of placental separation?

A
  • Cord lengthening

- Trickle of PV blood

23
Q

What other drugs are used if Synto doesn’t work?

A
  1. Repeat Syntometrine (1ml)
  2. Syntocinon infusion (40iu in 500ml saline at 125ml/hr)
  3. Haemabate (carboprost) (250mcg IM every 15 mins up to 8 doses)
  4. Misoprostol (800mcg PR)
24
Q

What are the advantages of using Haemabate?

A
  • Can be given IM
  • Dose 250mcg
  • Can be given up to 2mg (8 doses)
25
Q

What are the disadvantages of using Haemabate?

A
  • Must not be given IV
  • Can cause nausea, dizziness, flushing, headache
  • Caution with hypertension, cardiac disorders, pulmonary disease and asthma
26
Q

How does Misoprostol work?

A

Induces uterine contractions

27
Q

What additional drug can be used?

A

Tranexamic acid

28
Q

What additional management is required for a severe PPH?

A
  • CVP line and monitoring
  • Early transfer to theatre
  • Balloon tamponade
  • B lynch suture/ embolise uterine vessels/ hysterectomy if required
29
Q

What is an inverted uterus?

A

The passage of the fundus through the cervix (partial or complete)

30
Q

What are some signs of an inverted uterus?

A
  • Uterus may be seen outside vagina
  • Uterus palpated lower than usual
  • Shock disproportionate to blood loss
31
Q

How should an inverted uterus be treated?

A
  • Call for help
  • Manually replace uterus
  • Monitor ABC
  • Treat vasovagal shock
32
Q

What are the additional measures if the manual replacement of an inverted uterus is unsuccessful?

A
  • Tocolysis
  • Hydrostatic measures
  • Surgical replacement
33
Q

What are the risk factors for uterine rupture?

A
  • Previous uterine surgery/ trauma
  • Oxytocin use for multips
  • Forceps delivery
  • Previous CS and oxytocin in this labour
  • IOL with prostaglandins
  • Cephalopelvic disproportion
34
Q

What are the signs and symptoms of uterine rupture?

A
  • Sudden change in FHR
  • Abdominal pain
  • Change in abdominal shape
  • Palpable foetal parts
  • Vaginal bleeding
  • Cessation of contractions
  • Maternal tachycardia
35
Q

What is the treatment for uterine rupture?

A

Surgical repair/ Hysterectomy

36
Q

How should lacerations be managed?

A
  • Rapid identification of bleeding points
  • Pressure
  • Prompt repair
37
Q

How should haematomas be managed?

A
  • Require drainage

- Litigation of bleeding points

38
Q

What is the definition of a retained placenta?

A

One that is not delivered within 30 minutes of active management

39
Q

What must you NOT do with a retained placenta?

A

Excessive CCT

40
Q

How is a retained placenta treated?

A
  • Keep uterus well contracted
  • Manual removal if placenta not delivered in 2 hours or bleeding not controlled
  • Intra-umbilical oxytocin (injected into placental site to reduce rates of manual removal)
41
Q

What is placenta accreta?

A

Morbidly adherent, infiltrating the endometrium

42
Q

What is placenta increta?

A

Invades into the myometrium

43
Q

What is placenta percreta?

A

Invades through the myometrium into the serosa

44
Q

When is placenta accreta etc usually identified?

A

Not until manual removal takes place

45
Q

What is the conservative management for placenta accreta etc?

A

Leave in situ and give antibiotics

46
Q

What is the surgical management for placenta accreta etc?

A

Hysterectomy

47
Q

What are some signs of pre-existing blood conditions?

A
  • Watery blood loss
  • No evidence of clotting
  • Oozing from puncture sites
  • Bruising
48
Q

How should women with pre-existing blood conditions be treated?

A
  • Treat the underlying condition
  • Involve Haematologist
  • Transfusion of blood if needed
49
Q

What are the 5 things to consider when treating a major PPH?

A
  1. Communication
  2. Initial assessment
  3. Monitoring and investigations
  4. Medical treatment
  5. Surgical treatment
50
Q

Major PPH Treatment - Communication

A
  • Call for help
  • Alert blood transfusion
  • Alert consultant on call
51
Q

Major PPH Treatment - Initial Assessment

A
  • ABC - oxygen mask (15L)
  • Fluid balance
  • ?Blood transfusion
  • Keep patient warm
52
Q

Major PPH Treatment - Monitoring and Investigations

A
  • 14 gauge cannula x 2
  • FBC, coagulation, Us&Es, LFTs, X match
  • ECG
  • Foley catheter
  • Hb bedside testing
  • ?Central/ arterial lines
  • Documentation
  • Weight all swabs (EBL)
53
Q

How many units should be cross matched?

A

4

54
Q

Major PPH Treatment - Medical

A
  • Rub up contractions
  • Empty bladder
  • Drugs
55
Q

Major PPH Treatment - Surgical

A
  • Is the uterus contracted?
  • Examination under anaesthetic
  • Has any clotting abnormality been corrected?
  • Intrauterine balloon tamponade
  • Brace suture
  • Consider interventional radiology