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Postpartum Haemorrhage PPH - Coggle Diagram
Postpartum Haemorrhage PPH
Definition
Primary PPH
Vaginal bleeding in exess of 500ml in the first 24 hrs after birth
Secondary PPH
Abnormal vaginal bleeding from 24hr postpartum to 6 weeks (12 weeks)
Secondary PPH
Causes
Uterine infection / endometritis
REtained products of conception
Managment
Hx, exam
Vitals
Abdomenal exam - involuted appropriately
Speculum exam
VE - to see if cervix is closed
Bloods
FBC
CRP
G&S
Blood culture if temperature
Swabs
TV US scan
Abx - Co-amoxiclav +/- gentamicin
Evacuation of retained products of conception (ERPC) abx on board
Primary PPH
Atonic uterus continues to bleed at placental surface
May also be trauma / tears
Causes
The 4 T's
Tone -
Atonic
uterus
Tissue - Retained placenta / products
Trauma - Genital tract trauma
Throbin - Bleeding disorder
Risk Factors
Previous PPH 2-3x more likely
Multiple pregnancy
Macrosomia
Polyhydramnios
APH
Abnormal placetation
Precipitious / prolonged labour / chorioamnionitis
CS / forceps / vaccum / episiotomy / MROP / GA
Anaemia
Relating to distension of the uterus - stretch issue
Prevention / Mitigation
Prevent / treat anaemia
3rd stage / CS
Prophylactic Oxytocin bolus IM/IV
Previous PPH
Prophylactic bolus IV/IM and 40iu infusion IV
Presence of risk factors
Prophylactic bolus IV/IM and 40iu infusion IV
Emergency Care
Management
Call for help
ABC / MDT appraoch
Resus
Oxygen and lay flat
IV access x2 / Arterial line
Fluid resus / blood products
Crystalloid and colloid then blood procuducts
Baseline bloods
FBC
Coag
Inc fibrinogen
X match
Renal
LFT
Catheterise
Monitor urine output
Empty bladder to allow uterine contactions
Resus details
Continuos monitoring of vital signs / temp
Keep pt warm
Infuse warmed fluids w pressure bag
2L crystalloid
1.5L colloid
Awaiting blood
Transfusion decision - clinical / haematological
First O neg
Group specific
Full cross match
4u RBC / FFP
Recommendations:
Hb >8
Fibrinogen >2g PT
APTT <1.5N
Platelets >50
Specific Managment
Empty the uterus
Massage
Empty bladder
Digital explusion
Maintain Uterine contraction
Oxytocic agent
EUA / Remove products / Repair tears
If placenta not delivered in 30 min
Pharaclogical Rx
Uterotonic Agents
Oxytocin
Uterine contraction
1️⃣ line
Ergometrine
2️⃣ line
Uterine contraction and vasocontriction
Carboprost / Haemabate
Prostaglandin F1α
Uterine contractility
IM / Myometrial
Misoprostol
Admin
Vaginal / Rectal /buccal / sublingual
Surgical Care
Examination under anaesthesia (EUA)
Look for retained membranes/placenta.
Bimanual compression
Manual removal of placenta
Packing the uterus
Intrauterine balloon / tamonade balloon
Compression Suture
Stepwise Devascularisation of Uterus
Embolisation
Interventional radiology
Caesarean Hysterectomy
Cell Salvage
Guidelines
Royal college of Obstetricians & Gynaecologists
