1 of 19
Post partum haemorrhage
Published on Feb 06, 2019
No Description
MORE DECKS TO EXPLORE
PRESENTATION OUTLINE
Post partum haemorrhage
pathophysiology & emergency management of rapid blood loss
Describe pathophysiology of rapid blood loss.
Identify risk groups for PPH
Identify causes of PPH
Outline emergency management of rapid blood loss.
Clinically assess blood loss
Outline best practice of management of third stage labour.
Identify risk groups for PPH
Identify causes of PPH
Outline emergency management of rapid blood loss.
Clinically assess blood loss
Outline best practice of management of third stage labour.
Photo by Alex Hockett
definitions
when is post partum blood loss considered haemorrhage?
Traditionally Postpartum Haemorrhage is blood loss of 500ml or more puerperium (birth to 6/52). While blood loss >1000mls was a severe PPH.
Primary PPH refers to blood loss 500mls or more within the first 24 hours following delivery, Women may or may not be hemodynamically compromised.
Secondary PPH refers to blood loss >= 500mls from 24hours to 6/52 postpartum
Primary PPH refers to blood loss 500mls or more within the first 24 hours following delivery, Women may or may not be hemodynamically compromised.
Secondary PPH refers to blood loss >= 500mls from 24hours to 6/52 postpartum
Photo by Slava Murava Kiss
Pathophysiology
blood flow/blood volume
Blood flow to the placental bed varies with gestation. But at term it is approximately 750mls/min.
Maternal blood volume is approximately 7litres in late pregnancy. Ranzcog equation 100ml/kg (eg 7000ml = a 70kg women, 5000mls = 50kg women)
Note normal adult blood volume is 5L (70ml/kg). A 2L difference
30% of unreplaced blood volume is life threatening and can happen within minutes. (30% of 7L equates to 2.1 litre loss, while 30% of 5L = 1.5L).
Maternal blood volume is approximately 7litres in late pregnancy. Ranzcog equation 100ml/kg (eg 7000ml = a 70kg women, 5000mls = 50kg women)
Note normal adult blood volume is 5L (70ml/kg). A 2L difference
30% of unreplaced blood volume is life threatening and can happen within minutes. (30% of 7L equates to 2.1 litre loss, while 30% of 5L = 1.5L).
Photo by sari_dennise
frequency
Incidence of pph
Occurs in 5-15% of all births.
Majority occurring in the first 4 hours following birth.
Majority of cases occur in women without risk factors, they are usually minor and cause little or no morbidity.
Remains the leading cause of preventable morbidity and mortality globally and in Australia & New Zealand.
Majority occurring in the first 4 hours following birth.
Majority of cases occur in women without risk factors, they are usually minor and cause little or no morbidity.
Remains the leading cause of preventable morbidity and mortality globally and in Australia & New Zealand.
Photo by Patricia Prudente
Aetiology
uterine contraction
vasoconstriction
platelet aggregation
clot formation
Principle physiological mechanism for reducing PPH is the constricting of the blood vessels supplying the placental bed by means of uterine contraction.
Contractions are complimented by common haemostasis:
* Vasoconstriction
* Platelet aggregation and
* Clot formation
Contractions are complimented by common haemostasis:
* Vasoconstriction
* Platelet aggregation and
* Clot formation
managing pph
Rub up a contraction
Expel any clots from vagina and uterus
Call for help
Airway, Breathing, Circulation (ABC)
2 large-bore cannulas 14-16 gauge
Fluid replacement (Warm Crystalloid at 3 x volume lost)
Blood tests Cross match FBC, Coagulation studies
Empty bladder (insert IDC)
Oxygen
Expel any clots from vagina and uterus
Call for help
Airway, Breathing, Circulation (ABC)
2 large-bore cannulas 14-16 gauge
Fluid replacement (Warm Crystalloid at 3 x volume lost)
Blood tests Cross match FBC, Coagulation studies
Empty bladder (insert IDC)
Oxygen
PPH Management
- rub up a contraction
- expel any clots from vagina and uterus
- airway, breathing, circulation (ABC)
- 2 large-bore cannulas 14-16 guage
- Fluid replacement (warm crystalloid at 3 x volume lost)
- blood tests cross match FBC, coagulation studies
- Empty bladder (insert IDC)
- Oxygen
While most cases of PPH have no risk factors, there are significant identifiable antenatal and intrapartum indicators that place women at risk.
Causes of PHH (Identified as 4T’s)
Tone 70%
Tissue 20%
Trauma 10%
Thrombin 1%
Causes of PHH (Identified as 4T’s)
Tone 70%
Tissue 20%
Trauma 10%
Thrombin 1%
Photo by veen
the 4 t's
- Tone (70%)
- Tissue (20%)
- Trauma (10%)
- Thrombin (1%)
Causes of PPH
The 4 T's
tone
tissue
trauma
thrombin
The 4 T's
tone
tissue
trauma
thrombin
Photo by chrisinplymouth
antenatal risks
pph
Pre-eclampsia
Previous Caesarean Section
Primiparity
Grand Multi(over 5 pregnancies)
Induction of Labour
ITP (Idiopathic Thrombocytopenic Purpura)
Polyhydramnios
Multiple gestations or over distended uterus
Vonwillibrands (haemolytic disease)
Previous PPH
History of retained placenta
Placenta- Position Previa/APH
Maternal age≥35years
Abnormal placenta accreta, percreta or increta
BMI≥35𝑘𝑔𝑠/𝑚2
Intrauterine fetal death
Therapeutic anticoagulation
Disseminating Intravascular Coagulatin(DIC)
Previous Caesarean Section
Primiparity
Grand Multi(over 5 pregnancies)
Induction of Labour
ITP (Idiopathic Thrombocytopenic Purpura)
Polyhydramnios
Multiple gestations or over distended uterus
Vonwillibrands (haemolytic disease)
Previous PPH
History of retained placenta
Placenta- Position Previa/APH
Maternal age≥35years
Abnormal placenta accreta, percreta or increta
BMI≥35𝑘𝑔𝑠/𝑚2
Intrauterine fetal death
Therapeutic anticoagulation
Disseminating Intravascular Coagulatin(DIC)
Photo by JCHaywire
Intrapartum
risks
Prolonged 1st and 2nd stage
Prolong active third stage (>30minutes)
Use of Oxytocics
Assisted Birth (forceps, vacuum)
Arrest of descent
Episiotomy
Lacerations: cervical vaginal perineal or uterus
Precipitate labour
Uterine infection
Intrapartum haemorrhage
Amniotic Fluid Embolism (AFE)
Disseminated Intravascular Coagulation(DIC)
Prolong active third stage (>30minutes)
Use of Oxytocics
Assisted Birth (forceps, vacuum)
Arrest of descent
Episiotomy
Lacerations: cervical vaginal perineal or uterus
Precipitate labour
Uterine infection
Intrapartum haemorrhage
Amniotic Fluid Embolism (AFE)
Disseminated Intravascular Coagulation(DIC)
Photo by DFAT photo library
post partum
risks
Drug induced hypotonic(eg MgSO4,anaesthetic agent)
Bladder distension
Retained placenta or products of conception
Manual removal of placenta
Uterine inversion
Cervical, uterine or perineal lacerations
Caesarean section
AFE/DIC
Bladder distension
Retained placenta or products of conception
Manual removal of placenta
Uterine inversion
Cervical, uterine or perineal lacerations
Caesarean section
AFE/DIC
Photo by derPlau
prevention
primary pph
Treat anaemia during ante-natal period
Avoid routine episiotomy
Active management of the 3rd stage
Check for signs of genital trauma and repair
Check for completeness of placenta and membranes
Close observations and early intervention in early postpartum
Avoid routine episiotomy
Active management of the 3rd stage
Check for signs of genital trauma and repair
Check for completeness of placenta and membranes
Close observations and early intervention in early postpartum
Photo by KayVee.INC
routine
assessment following birth
Palpation of fundus (height, position &tone)
Check vital signs
Recognise and weight blood loss
Identify cause of blood loss and treat
Empty bladder early (IDC insert)
Overall assessment of the woman’s condition and intervene early and escalate
Check vital signs
Recognise and weight blood loss
Identify cause of blood loss and treat
Empty bladder early (IDC insert)
Overall assessment of the woman’s condition and intervene early and escalate
Photo by Shooting Chris
step wise approach
Photo by CDC Global Health
Trauma
PPH
