Postpartum-Haemorrhage 2 slides.ppt

Description of postpartum hemorrhage and how to manage

1. Postpartum Haemorrhage

2. Definitions
•Primary PPH –blood loss of 500ml or more
within 24hours of delivery.
•Secondary PPH –significant blood loss
between 24 hours and 6
weeks after birth.

3. Why do we care?
Major obstetric haemorrhage –more than
1000ml
Very rapidly lead to maternal death

4. •3
rd
highest cause of direct maternal death in
the UK and Ireland (2003-2005)
•58% of these cases care was “seriously
substandard”
•Major cause of severe maternal morbidity in
“near-miss audits”

5. Risk Factors
Most cases have no risk factors
•Previous PPH
•Antepartumhaemorrhage
•Grand multiparity
•Multiple pregnancy
•Polyhydramnios
•Fibroids
•Placenta praevia
•Prolonged labour (&oxytocin)

6. Prevention
•Be aware of risk factors –may present antenatally
or intrapartum
•Treat anaemia antenatally
•Active management of the 3
rd
stage
•Prophylactic oxytocicsreduce the risk of PPH by
60% (oxytocinor oxytocin& ergometrine)
•5IU IM for vaginal delivery
•5IU IV for LSCS
•Consider oxytocininfusions

7. 4 T’s
Tone
Tissue
Thrombin
Trauma

8. Causes
Tone
Previous PPH
Prolonged labour
Age > 40 years
Big baby
Multiple pregnancy
Placenta praevia
Obesity
Asian ethnicity
Tissue
Retained placenta/
membrane/clot

9. Thrombin
Abruption
PET
Pyrexia
Intrauterine death
Amniotic fluid embolism
DIC
Trauma
Caesarean section
(emergency > elective)
Perinealtrauma
Operative delivery
Vaginal and cervical tears
Uterine rupture

10. •Blood loss is commonly underestimated
•Loss may be well-tolerated
•Beware the “trickle” and the “moderate
lochia”
•Minor PPH can easily progress to major PPH.

11. Management
•Has the placenta been delivered and is it
complete?
•Is the uterus well-contracted?
•Is the bleeding due to trauma?

12. Resuscitation
A & B –10 -15l/min O2 by facemask
C - 2 14 gauge cannulae
blood for Hb, U&E, LFTs, clotting
crossmatch 4 units
2 litres of crystalloid rapidly
transfuse as soon as possible –consider O –
ve blood if any delays.

13. Uterine Contraction-First Line Drugs
•Oxytocin 5IU
•Oxtocin infusion –40IU in 500mls
•Ergometrine 0.5mg
•Carboprost (Haemabate©) 0.25mg IM every
15 minutes x 8 doses
•Misoprostol 600 mcg sublingually

14. Uterine Contraction –non-pharm
•Empty uterus
•Foley catheter
•Rub up a contraction
•Bimanual compression
•Balloon tamponade
•Brace suture
•Uterine artery ligation
•Internal iliac artery ligation
•Interventional radiology

15. •Hysterectomy –before it’s too late

17. B-Lynch Suture

18. Balloon Tamponade

19. Haematological Management
DIC
•Transfuse without delay
•Involve haematology service at an early stage
•Correct coagulopathy
•Liase with consultant haematologist re use of
recombinant Factor V11 (Novoseven©) and
Fibrinogen.

20. •Traumatic for patient, family and staff.
•Debriefing for patient and staff.
•Case analysed to ensure care was of good
standard and any substandard care can be
improved.

21. Secondary PPH
•Infection
•Retained placenta
•Trophoblastic disease
•Antibiotics
•Evacuation of retained products if bleeding
persistent or significant amount of tissue
retained.