PPH
PPH
PPH
INTRODUCTION
Haemorrhage is the third commonest cause of direct maternal death (CEMACE 2007). Obstetric haemorrhage can quickly become life-threatening
G Excessive blood loss at or after delivery of fetus (see above for volumes) in first 24 hr. Affects approximately 5% of all deliveries in the UK
G Normal blood volume from 13/40 is approximately 100 mL/kg G Acceptable blood loss at vaginal delivery is 500 mL G Acceptable blood loss at caesarean section is 1000 mL
G Excessive blood loss from genital tract >24 hr after birth and within 12 weeks of delivery
Blood Loss
Table 1: Classification of haemorrhage Use as a guide always treat symptomatic women regardless of blood loss Class Volume loss Clinical signs 1 <15% Minimal mild tachycardia G Normal BP unchanged pulse pressure , G Normal respiratory rate G Normal urine output 2 1530% Moderate tachycardia (110130 bpm) G Normal or slightly decreased BP (diastolic pressure , increasing) G Moderate increase in respiratory rate G Decreased urine output G Subtle CNS/mental changes (e.g. anxiety) Significant marked tachycardia (120160 bpm) 3 3040% G Decreased systolic BP G Marked increase in respiratory rate G Marked decrease in urine output G Obvious CNS/mental changes (e.g. drowsiness) G Cold, clammy skin Severe/life-threatening 4 >40% G Marked tachycardia G Systolic BP <80 mmHg G Absent peripheral pulses G Severe oliguria or anuria G Marked increase in respiratory rate G Obvious CNS/mental changes (e.g. confusion or unconsciousness) G Cold, clammy skin
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G Hypertensive diseases in pregnancy G Multiple pregnancy G Previous PPH G Previous caesarean section G Antepartum haemorrhage G Obesity G Age >40 yr G Anaemia
G G G G G G G
Table 3: Cause of haemorrhage (the four Ts) G Atonic uterus G Cervical, vaginal or perineal lacerations G Pelvic haematoma G Inverted uterus G Uterine rupture C Tissue G Retained tissue G Invasive placenta (accreta) D Thrombin G Coagulopathies A Tone B Trauma 4 Ts Specific cause Relative frequency 70% 20%
10% 1%
G Women at increased risk of bleeding, active management of third stage advised G Give syntometrine (ergometrine and oxytocin) 1 mL IM in third stage G For hypertensive woman or those whose blood pressure has not been checked before delivery, give 5 or 10 units oxytocin IM or slow IV bolus
G Summon help senior obstetrician, anaesthetist, senior midwife and ancillary staff if necessary G Consider: G A AIRWAY check airway not compromised G B BREATHING oxygenate with 15 L/min O2 via face mask
Issue 1 Issued: February 2011 Expires: February 2013
G C CIRCULATION obtain venous access insert large bore 14 or 16 gauge cannula and take bloods for FBC, clotting screen, Group & save and crossmatch if required (see Major haemorrhage below) G Palpate uterus for atony and commence fundal massage. Consider bimanual compression G Empty bladder to assist with uterine contraction G Commence oxytocin infusion use local regimen for postpartum G Monitor pulse and blood pressure every 15 min initially
G Classification 2,3,4 (see table 1) G Simultaneously perform resuscitation, monitoring, arresting bleeding and communication
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Oxygen
G Estimate blood loss by direct observation of overt blood loss AND clinical signs of intra-abdominal blood loss G Summon help: G obstetric registrar G anaesthetist (resident registrar or staff grade) G senior midwives (e.g. midwife coordinator and another experienced midwife) G other personnel (e.g. porter/auxiliary/HCA to run errands etc) G Take blood for: G FBC G APTT G PT (INR) G crossmatch (at least 4 units of packed red cells. Consider requesting type specific blood in a dire emergency. Consider requesting FFP) G U&E, creatinine and Kleihauer and cannulate, (insert two 16 or 14 gauge venous cannulae one in each arm) G Give fluids one litre compound sodium lactate (Hartmanns) solution stat G Follow with blood, colloid or crystalloid as indicated by availability, blood loss and womans haemodynamic state G Do not give more than 3.5 L clear fluids [up to 2 L compound sodium lactate (Hartmanns) solution and 1.5 L colloid] while waiting for blood G Prepare blood/fluid warmer(s) to use as soon as possible especially for blood products. Keep woman warm
Monitoring
Bloods
Urinary catheter
Inform
Fluids
Specific treatment
Blood/fluid warmer
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Reassess
G Suspect if massive (>10 units blood) transfusion with ongoing hypotension, check Ca2+. Give 1020 mL calcium gluconate 10% by slow IV infusion. Ensure ECG monitoring when administering calcium gluconate
Hypocalcaemia
Post event
G Unless advised to be inappropriate by consultant obstetrician/anaesthetist, thromboprophylaxis is required regardless of mode of delivery once bleeding has settled G These women are at increased risk of thromboembolism, consider antiembolic stockings and other methods of mechanical thromboprophylaxis whilst being nursed in HDU, and give low molecular weight heparin
Thromboprophylaxis
G Within a reasonably short time period, consultant obstetrician should counsel woman and her family providing explanation and significance of cause of haemorrhage G Ideally midwife should remain with woman and family throughout the emergency situation
G Contraindicated for at least 12 hr after haemorrhage has settled and platelet count normal 103
G Oxytocin start oxytocin infusion. Use local regimen for postpartum via volumetric pump G Remember to inspect vulva, vagina and cervix for trauma/lacerations G Consider a first or repeat dose of oxytocin 5 or 10 units by slow IV bolus IM, ergometrine 250 microgram IM with an antiemetic [contraindicated in pregnancy induced hypertension (PIH) or other significant cardiovascular disease], misoprostol 1000 microgram PR or 250 microgram carboprost (methyl prostaglandin F2 Hemabate) IM or intramyometrially (may be repeated up to every 15 min to a maximum of 2 mg)
G Replace uterus as soon as possible using manual, hydrostatic or surgical methods G Anticipate massive haemorrhage G Some women may experience a vasovagal episode (hypotension and bradycardia) during uterine replacement
Continuing bleeding
G If above measures fail to prevent ongoing or recurrent bleeding, suspect Trauma, Tissue (e.g. retained products of conception) or Thrombin (e.g. a coagulopathy)
G Run an oxytocin drip 40 units in 500 mL of sodium chloride 0.9% at 125 mL/hr through a pump for at least 4 hr after replacement
Uterine rupture
G See Uterine rupture guideline
G Consider surgical examination under anaesthesia G if woman haemodynamically stable, use pre-existent regional (epidural) anaesthesia G if woman not stable or (dilutional) coagulopathy present, use general anaesthesia
Perineal trauma
G See Third and fourth degree perineal tears guideline
Other
G Broad ligament haematoma G Extra genital bleeding e.g. sub capsular liver rupture
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Acquired coagulopathies
G Will often represent a form of disseminated intravascular coagulation (DIC) and will usually result in continuing or worsening haemorrhage without blood product replacement therapy G Suspect DIC in abruption, severe PIH, prolonged +/- infected retained fetus/products of conception, amniotic fluid embolism or prolonged/untreated hypovolaemic shock
Risk factors
G Previous retained placenta G Caesarean section G Placenta praevia G D&C
G FBC, PT, INR, APTT, and APTTR in the first instance in all those conditions where there is a known associated complication of DIC G If platelet count <50 x 109/L or INR >1.6, check fibrinogen and fibrinogen degradation products (FDP) levels G Seek advice of a consultant haematologist about treatment and further investigations
Placenta accreta/increta/percreta
G Once attempts made to separate adherent placenta (surgically/forcibly), expect massive haemorrhage G If expected or happens, follow management plan for major obstetric haemorrhage
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