Post-Partum Haemorrhage
Post-partum haemorrhage (PPH) =
- an estmated blood loss >500ml after vagnnal delnver R
- an estmated blood loss >1000ml after C-setton R
- a >10% drop nn haematotrnt from admnssnon; R
- Blood loss (ma be tontealed) resultng nn maternal haemod namnt nnstabnlnt
EPIDEMIOLOGY
5% of all deliveries (4% after vagnnal --8% after C-setton)
AETIOLOGY
Prnmar PPH (<24hrs after delnver )
4T’s
Tone (aton ) – 90%
Trauma (pernneal tervntal)
Tissue (retanned platenta)
Thrombophilia (toagulopath )
Description Management
TONE (Uterine The loss of tone nn uternne mustulature so 1) Fundal massage
Atony) that uternne tontratton tannot tompress 2) Bimanual compression (fist nn anternor fornnx wnth other
vessels and redute fow. Thns ma lead to hand on abdo to squash uterus)
atute bleednng. 3) Medntal uterotonnt therap :
- Oxytocin - 10-40 unnts/1L or ma be gnven IM or
Confirm b examnnnng uterus whnth should be nntra-m ometrnal (note: IV can cause hypotension)
hard and tontratted but nnstead wnll be soft - Ergometrine – 0.2mg IM 2hrl max 3 doses (note:
and bogg . avoid in hypertension! eclampsia)
Extlude retanned platental fragments Syntometrine® = Rx totnn + Ergometrnne
(examnne platenta for mnssnng parts). - Carboprost/Hemabate (15-methyl-prostaglandin
F2α) - 0.25mg IM or nntra-m ometrnal ever 15-
nsk fattors 20mnns max 8 doses (note: avoid in asthma)
Uternne over-dnstenton - Misoprostol (PGE1) – 1000mg rettall
(pol h dramnnos multple pregnant - Dinoprostone (PGE2) – 20mg rettall
foetal matrosomna) 4) Further treatment:
Hngh parnt Consent, IV access, Anaesthesia, Anbx, Empty bladder
Prolonged labour - Tamponade - Bakri balloon or Foley catheter (nn
Prnor uternne aton tondom) – filled wnth 200-500ml water
Uternne relaxnng agents (MgSR4 - Uterine packing
Nnfednpnne Terbutalnne Anaesthett) - Angiography and embolization
- Exploratory laparotomy with surgery (anternor
branth of nnternal nlnat arter lngaton or
hysterectomy)
TISSUE (Retained Fanlure of a platenta to delnver wnthnn Treatment:
placental 30mnns after whnth manual removal ma Consent, IV access, Anaesthesia, Anbx, Empty bladder
fragments) begnn (or earlner nf there ns extessnve 1) Platental separaton tan be entouraged b “controlled
bleednng). cord traction” usnng enther
Seen nn 3% of platentas. - Brandt-Andrews manoeuvre – uterus ns setured
nsk fattors suprapubntall and tontrolled tratton ns applned to
Uterine atony the tord
Abnormal placentation (e.g. attreta) - Credé manoeuvre – tord ns setured and uterus
Trapped placenta (platenta tomes awa elevated
but trapped behnnd semn-tlosed tervnx) 2) Dilation and curetage (USS-gunded)
Presentaton
Heav bleednng +/- passage of tlots
Foul smellnng Lothna
Abdo tramps
Fever
Latk of lattaton (progesterone stll hngh)
TRAUMA (Lower T pes 1) Surgical repair of tear -
genital tract Cervntal tears +/- evacuate haematoma if present (concealed)
Post-partum haemorrhage (PPH) =
- an estmated blood loss >500ml after vagnnal delnver R
- an estmated blood loss >1000ml after C-setton R
- a >10% drop nn haematotrnt from admnssnon; R
- Blood loss (ma be tontealed) resultng nn maternal haemod namnt nnstabnlnt
EPIDEMIOLOGY
5% of all deliveries (4% after vagnnal --8% after C-setton)
AETIOLOGY
Prnmar PPH (<24hrs after delnver )
4T’s
Tone (aton ) – 90%
Trauma (pernneal tervntal)
Tissue (retanned platenta)
Thrombophilia (toagulopath )
Description Management
TONE (Uterine The loss of tone nn uternne mustulature so 1) Fundal massage
Atony) that uternne tontratton tannot tompress 2) Bimanual compression (fist nn anternor fornnx wnth other
vessels and redute fow. Thns ma lead to hand on abdo to squash uterus)
atute bleednng. 3) Medntal uterotonnt therap :
- Oxytocin - 10-40 unnts/1L or ma be gnven IM or
Confirm b examnnnng uterus whnth should be nntra-m ometrnal (note: IV can cause hypotension)
hard and tontratted but nnstead wnll be soft - Ergometrine – 0.2mg IM 2hrl max 3 doses (note:
and bogg . avoid in hypertension! eclampsia)
Extlude retanned platental fragments Syntometrine® = Rx totnn + Ergometrnne
(examnne platenta for mnssnng parts). - Carboprost/Hemabate (15-methyl-prostaglandin
F2α) - 0.25mg IM or nntra-m ometrnal ever 15-
nsk fattors 20mnns max 8 doses (note: avoid in asthma)
Uternne over-dnstenton - Misoprostol (PGE1) – 1000mg rettall
(pol h dramnnos multple pregnant - Dinoprostone (PGE2) – 20mg rettall
foetal matrosomna) 4) Further treatment:
Hngh parnt Consent, IV access, Anaesthesia, Anbx, Empty bladder
Prolonged labour - Tamponade - Bakri balloon or Foley catheter (nn
Prnor uternne aton tondom) – filled wnth 200-500ml water
Uternne relaxnng agents (MgSR4 - Uterine packing
Nnfednpnne Terbutalnne Anaesthett) - Angiography and embolization
- Exploratory laparotomy with surgery (anternor
branth of nnternal nlnat arter lngaton or
hysterectomy)
TISSUE (Retained Fanlure of a platenta to delnver wnthnn Treatment:
placental 30mnns after whnth manual removal ma Consent, IV access, Anaesthesia, Anbx, Empty bladder
fragments) begnn (or earlner nf there ns extessnve 1) Platental separaton tan be entouraged b “controlled
bleednng). cord traction” usnng enther
Seen nn 3% of platentas. - Brandt-Andrews manoeuvre – uterus ns setured
nsk fattors suprapubntall and tontrolled tratton ns applned to
Uterine atony the tord
Abnormal placentation (e.g. attreta) - Credé manoeuvre – tord ns setured and uterus
Trapped placenta (platenta tomes awa elevated
but trapped behnnd semn-tlosed tervnx) 2) Dilation and curetage (USS-gunded)
Presentaton
Heav bleednng +/- passage of tlots
Foul smellnng Lothna
Abdo tramps
Fever
Latk of lattaton (progesterone stll hngh)
TRAUMA (Lower T pes 1) Surgical repair of tear -
genital tract Cervntal tears +/- evacuate haematoma if present (concealed)
