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Postpartum Haemorrhage

Terms in this set (17)

CMO CTCS: Labour, birth, and immediate postpartum
Transfer of care: hemorrhage unresponsive to therapy
CMO CTCS: Postpartum
Consultation: secondary postpartum hemorrhage
Benefits of AMTSL (5)
1. Less blood loss > 500 ml
2. Reduced risk of PPH
3. Hemoglobin > 90
4. Less need for blood transfusion
5. Less need for additional uterotonics
Midwifery management
Tone
Tissue
Trauma
Thrombin
(Tinkle)
Tone Etiology
Accounts for 70% of PPH cases
Exhaustion of uterine muscles
Over-distended uterus
Chorioamnionitis
Anatomic distortion of the uterus
Uterine-relaxing agents
Management: Tone (7)
1. Uterine massage
2. Oxytocin 10 IU IM/5 IU IV push/20-40 IU in 1000 ml NS IV infusion

3. If bleeding continues, use other uterotonics:
Oxytocin again
Ergonovine 0.25 mg IM/IV q 2 hours
Carboprost 0.25 mg IM/IMM q 15 minutes
Misoprostol 200-400 PO/SL and 400-800 PR
Carbetocin 100 mcg IM/IV

4. Empty bladder

5. If bleeding continues, uterine tamponade - bimanual compression
6. start 2nd IV

7. Obviously you's also callin' for help!
Tissue Etiology
accounts for 10% of PPH
Retained placenta: placental fragments, clots, lobe or membranes
Abnormal placentation: accreta/increta/percreta
Management: Tissue (4)
1. Administer oxytocin and apply cord traction while guarding uterus
2. Consider umbilical cord drainage
3. Follow umbilical cord with sterile glove to determine if placenta is separated but trapped in the cervix. If palpable, deliver
4. Manual removal of placenta if all else fails and no physician is available immediately
Trauma etiology
accounts for 20% of PPH cases
Lacerations and hematomas of vagina, perineum or cervix
Laceration at CS/extension of incision
Uterine rupture
Uterine inversion
Management: Trauma (5)
1. Ensure adequate lighting and exposure, consider analgesia to inspect lower genital tract for lacerations
2. Repair tears in vagina/perineum
3. Consider packing vagina or repair severe lacerations during transport
4. If cervical tear, apply pressure with gauze on ring forceps until obstetrical assistance is obstained
5. Consider hematoma
Thrombin etiology
Accounts for 1% of PPH
Preexisting coagulation disorders
Therapeutic anti-coagulant use
Management: thrombin (2)
1. Obtain 2-5 ml of client's blood in a red top tube and set aside to observe. Blood will normally clot and stay clotted within 8-10 minutes. If clot does not form or if it breaks down easily, this suggests coagulopathy.
2. Treat for hypovolemic shock while awaiting transport and/or consult.
Definition
Any amount of blood that causes a woman to exhibit signs and symptoms of hemodynamic instability - this amount may be lower than 500 ml in a patient with dehydration or anemia.

Severe: blood loss >1000 ml following vaginal delivery

Primary: hemorrhage occurring within 24 hours following birth

Secondary: hemorrhage occurring between 24 hours and 6-10 weeks postpartum
Incidence
6% of births worldwide
5.1% in Canada

Secondary: 1.86% of all births worldwide
Birth position and its effect on PPH
Sitting on hard surface of birthing stool or chair may obstruct venous return and therefore lead to an increase in blood loss from perineal damage.

Upright positions might cause increased hydrostatic pressure both on the arterial and venous side which would contribute to increased bleeding form the uterus and placental site.

Hypothesized that upright birthing positions may affect the production of prostaglandins that play a role in the placental separation and therefore contribute to uterine atony.

Increased blood loss from sitting positions originate from perineal trauma.

Squatting found no difference in blood loss between upright and supine position because venous return was not obstructed.
Signs and Symptoms of Shock
Initial: pallor, slight anxiety, cool extremities

Compensatory: oliguria, tachycardia, tachypnea, dilated pupils, diaphoresis, delayed cap refill, anxiety, restlessness, agitation, postural hypotension

Progressive: hypotension, weak or absent pulse, altered mental status

Final: organ system failure and cell destruction becomes irreversible
Estimating Blood Loss
Grossly underestimated by 33-50%

Provider specialty, age, or years of experience were not related to accuracy of visual estimated blood loss

Accurate and timely recognition of excessive blood loss by clinicians is crucial because it leads to initiation of blood transfusions and other resuscitative efforts. Overestimation can lead to costly, invasive, and unnecessary treatments while underestimation can lead to delay in lifesaving interventions.
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