614 OSCE HAEMORRHAGEA PPH postpartum hemorrhage postpartum genital tract bleeding after the birth of a baby, over 500mls or any amount that adversely affects the mother. Primary postpartum hemorrhage occurs within the first 24 hours, secondary postpartum hemorrhage occurs after this usually around day 10. Differential ranges of 4 11% of all births. Possible risk factors for pregnancy after birth macrosomia Grandmultiparity Polyhydramnios haemorrhageMultiple retained placenta Placenta previa increased labor antepartum haemorrhage Instruction Section previous caesarean birth PTT clotting disorders There are 4 categories Tone causing postpartum hemorrhage (70%) trauma Tissue Trauma Grand multiparity The multiple pregnancy Polyhydraminos Macrosomia Abnormalities: Fibroids Prolonged labor Precipitate job Dysfunsctional job Intrauterine infection Br uterine relaxant agents (Magnesium / general anesthesia / tocolytics) Operative delivery Cervical vaginal tears / Previous caesarean section increases the risk of morbidity due to adherence of the placenta Retention of placental tissue or membranes Preeclampsia HELLP Syndrome Placental abruption Amniotic fluid embolism Sepsis Bleeding disorders Drugs (aspirin and heparin) the possible consequences of maternal treatment PPHShock hysterectomy DIC primary postpartum hemorrhage Call for help Senior Obstetrician Senior midwife Anesthesiologist ODP Senior Midwife Type Porter Report Hematologist Venflons site of two largecaliber Take bloods FBC Coagulation (including platelets) Crossmatch Get 46 units of blood ready in case blood transfusion Stabilize the mother Frequently assess maternal observations (usually anesthesiologists S work) Maternal oxygen 8L/min Monitor fluid input / output IV crystalloid or colloid Hartmann / normal saline (not dextrose) 5ie, 10 minutes faster if PTT important IV plasma substitute (Haemacell 500mls) Include blood transfusion in the liquid at equilibrium Catheterise They need at least 30mls/hr Continuously assess the volume of blood loss Check uterine tone If LAX / swamp Rub a contraction Repeat / give syntometrine (or ergometrine) Syntometrine (1 ml = 5IU of Syntocinon and ergometrine 500mcg) Ergometrine 0.5mg (500mcg) IV Do not give if hypertensive Set Syntocinon IV 40IU/500mls normal saline over 4 hours (check policy) Haemobate / Carboprost 0.2 mg intramuscularly every 15 minutes (maximum 8 doses: 2 mg) Obstetrician can myometrically (directly into the uterus) A theater transfer for surgery if the bleeding does not stop Ata / cauterize all ligaments (blood flow) in the uterus Quickly assess for bleeding at the trauma site If the transfer of obvious trauma to the theater for the suture of the cervix, perineum, etc. It is the placenta in situ Try the placenta Be careful not to reverse the uterus Get someone to check the integrity if Transfer to the theater for manual removal if sticky or missing pieces Hematologist instruct if bleeding disorders May need additional clotting factors If you do not know why there is bleeding / not be stopped Obtain Consultant if not already present Apply bimanual compression Or compress the aorta (fist just above the navel and to the left if you can you feel the femoral pulse is not it t pressing hard enough) Consider CVP line (anesthesiologist to insert) Transfer to the theater if not already there GA Obstetrician to perform manual examination Possible uterine rupture Possible intraabdominal bleeding Broad Ligament Bruise Consider transfer to ITU when the bleeding under control May need additional blood transfusions or iron supplements Record keeping, as contemporaneously as possible, when writing notes include original type S transcripts controversial issues 10 women died of PPH in the last three years (tenfold increase from the previous three), although 2 pregnancies were hiding with a PPH at home unattended could have been treated and saved The main problem with such catastrophic bleeding that can occur DIC (disseminated intravascular coagulation), when this happens, the mechanism of blood coagulation quot; ****# it going to 39, with little blood clots in the capillaries it uses all clotting factors and means you can clot in which t s aims. If heparin is administered can cause clots to those minibreak and restore the system. However, Sa balancing act, very few cattle Do nothing, too much can kill Breastfeeding causes the body to release oxytocin, useful in case of minor bleeding or to encourage the placenta to come out The anemia does not increase the risk of postpartum hemorrhage, however, affect how women can cope with the loss of blood, so it can become symptomatic much earlier than someone with a high Hb. RCOG recommend that a balloon occlusion and arterial embolization are used to reduce the need for transfusions and hysterectomy when there is a known high risk of PPH The balloon is placed in the iliac and uterine arteries before the previous section on the scar of age or known placenta accreta. Due to the increased blood volume of healthy pregnant women long term, she won T show signs of shock until it has lost a good amount of blood (more than 1L) Don t assume that there is no danger, because BP is normal A Blynch suture, where the uterus is sown up and over, in a belt and braces fashion, can stop haemorrhage Effectively and preserve future fertility. Reading BLynch et al (1997) The BLynch technique for the surgical control of massive postpartum haemorrhage: an alternative to hysterectomy Five cases. British Journal of Obstetrics and Gynecology 104, 372:375 Confidential Inquiry into Maternal and Child Health (2004) that mothers die 20002002 Midwifery Summary and Key Findings Sixth Report of confidential inquiries into maternal deaths in the UK RCOG Press: London br RCOG (2007) The role of emergency and elective Interventional Radiology in postpartum hemorrhage Good Practice Press n 6 RCOG: London br br
