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Post Partum Hemorrhage
Transcript of Post Partum Hemorrhage
Most common cause of PPH
Bimanual Uterine Massage
Massage should be maintained while other interventions are initiated.
Atony Risk Factors
Overdistention (multiple gestation, hydamnios, macrosomia
Carboprost tromethamine (Hemabate)
Requires prompt initiation of uterotonic therapy and assessment of the effects of that therapy
If fundus is well contracted but bleeding continues, then further massage is not likely to be effective.
Retained products (succenturiate lobe, placental fragments, placenta accreta.
Uterine Fatigue (prolonged labor)
Please see medication section of this presentation.
One or more accessory lobes that develop at distance from the main placenta
Accreta, Increta, and Percreta
Inversion is almost always the consequence of strong traction on an umbilical cord attached to a placenta inplanted in the fundus.
Increase risk of bleeding at placental insertion site and can cause continued bleeding unresponsive to oxytocics.
Disseminated Intravascular Coagulation (DIC)
Post Partum Hemorrhage
Uterine Massage and Compresion
Bimanual uterine massage
If patient had previously identified risk factors for PPH, they should already have IV access with
or larger catheter.
Fluid Resuscitation and Transfusion
Uterine Exam and Treatment
Uterine exploration for retained products to be removed manually.
More common in twin placentas
May be a retained product
Only detected by OB US 33% of the time
Associated with immediate life threatening hemorrhage
Elevated Liver Enzymes
Perineal tears and lacerations
Rapid delivery/precip labor
Requires thorough inspection and repair.
Cervical and Vaginal lacs
Vaginal hematomas should not be drained unless expanding.
If bleeding continues but fundus well contracted, further massage is not likely to be effective.
Progress to other methods of hemorrhage control
Ensure TWO large bore IVs (16 or 18 gauge) for administration of fluids and blood.
should be placed to monitor adequate kidney perfusion
NS boluses increase the risk for metabolic acidosis secondary to hyperchloremia and should never be given to a woman who is hemorrhaging.
Isotonic cystalloid (
) rapidly infused to prevent hypotension and maintain urine output (>30 mL/hr)
Further transfusion as indicated.
Consider FFP for every 1-2 units PRBCs transfused until clinical situation stable.
2 units PRBCs given as soon as they are available if hemodynamics do not improve after 2-3 liters crystalloid.
Prothrombin Time (PT)
Activated Partial Thromboplastin Time (aPTT)
Estimate EBL q15-30 minutes
Draw labs q30-60 minutes
Oxygen @ 10 L NRB!
Begin administration of medications
Transfer to OR for D&C if manual removal is unsuccessful in controlling hemorrhage
Uterine tamponade with Bakri balloon and US guidance.
Follow instructions on packaging.
10 units IM or 20-40 units IV in 1000 mL.
Larger doses do not increase effectiveness and
To be used as adjuct to Pitocin, not primary therapy
0.2 mg IM. May repeat in 2-4 hour intervals if needed.
250 mcg IM every 15-90 minutes as needed. Max dose 2 mg (8 doses)
More effective than cytotec in the prevention of PPH
Give initially as bolus and titrate to control bleeding.
May begin IV pitocin administration with delivery of anterior shoulder.
Particularly useful when Methergine and/or Hemabate contraindicated
800 mcg sublinqual
nausea, diarrhea, abd pain, HA, maternal fever
If no good response with first dose, quickly move on to different uterotonic agent.
Contraindications: hypertension, preeclampsia.
HTN with HA or seizure, low BP, palpitations, N/V/D, dizziness, ringining in ears, SOB, CP, sweating, blood in urine, nasal congestion, leg cramps.
asthma or other acute pulmonary disease
bronchospasm, pulmonary HTN, N/V/D, chills & shivering, HA, severe cramps, hot flashes/flushing.
Weigh pads and chux:
1 mL blood = 1 gram
PPH if Blood Loss Greater Than or Equal to:
500 mL after vaginal birth
1000 mL after c-section
Remember that EBL is often significantly under estimated.
ATLS Hemorrhage Classifications:
Class I: 750 mL loss or 15% of blood
Volume restored within 24
hours without transfusion.
Class II: 750-1500 mL loss or 15-30%
of blood volume.
Needs IVF but not
Class III: 1500-2000 mL loss or
30-40% of blood volume.
Transfusion is needed.
Class IV: >2000 mL loss or
>40% of blood volume.
Life threatening, preterminal.