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Post Partum Hemorrhage

FBU Skills Fair 2014
by

Laura Reed

on 10 February 2014

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Transcript of Post Partum Hemorrhage

Uterine Atony
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
Uterotonic Drugs
Oxytocin (Pitocin)
Misoprostol (Cytotec)
Carboprost tromethamine (Hemabate)
Methylergonovine (Methergine)
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 inversion
Uterine Fatigue (prolonged labor)
Uterine relaxants
Uterine infection
Please see medication section of this presentation.
Succenturiate Lobe
One or more accessory lobes that develop at distance from the main placenta
Accreta, Increta, and Percreta
Risk Factors:
Uterine Inversion
Inversion is almost always the consequence of strong traction on an umbilical cord attached to a placenta inplanted in the fundus.
Placental Abnormalities
Increase risk of bleeding at placental insertion site and can cause continued bleeding unresponsive to oxytocics.
Coagulopathies
Disseminated Intravascular Coagulation (DIC)
HELLP Syndrome
Pertinent Labs
CBC
PTT
Fibrinogen
Post Partum Hemorrhage
Clinical Management
Uterine Massage and Compresion
Bimanual uterine massage
IV Access
If patient had previously identified risk factors for PPH, they should already have IV access with
18 gauge
or larger catheter.
Fluid Resuscitation and Transfusion
Crystalloid
Initial Labs

Uterine Exam and Treatment
Uterine exploration for retained products to be removed manually.
More common in twin placentas
May be a retained product
Previous c-section
Previous D&C
Increased gravida
Only detected by OB US 33% of the time
Associated with immediate life threatening hemorrhage
Hemolysis
Elevated Liver Enzymes
Low Platelets
Definitions
Trauma
Perineal tears and lacerations
Risk Factors:
Rapid delivery/precip labor
Fetal macrosomia
Instrumental delivery
Shoulder dystocia
Nulliparity
Non-vertex presentation
Requires thorough inspection and repair.
Cervical and Vaginal lacs
Vulval Hematoma
Uterine Rupture
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
promptly.
Ensure TWO large bore IVs (16 or 18 gauge) for administration of fluids and blood.
Foley catheter
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 (
LR
) rapidly infused to prevent hypotension and maintain urine output (>30 mL/hr)
Blood Components
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.
Monitor:
Fluid Overload
Clinical Management
Fibrinogen
Platelet count
Prothrombin Time (PT)
Activated Partial Thromboplastin Time (aPTT)
Identifies coagulopathies
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.
Medications
Pitocin
10 units IM or 20-40 units IV in 1000 mL.
Larger doses do not increase effectiveness and
cause
hypotension.
Cytotec (Misoprostol)
To be used as adjuct to Pitocin, not primary therapy
Methergine
0.2 mg IM. May repeat in 2-4 hour intervals if needed.
Hemabate
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
Oral dosing:
800 mcg sublinqual
Rectal dosing:
800-1000 mcg
Side effects:
nausea, diarrhea, abd pain, HA, maternal fever
If no good response with first dose, quickly move on to different uterotonic agent.
Contraindications: hypertension, preeclampsia.
Side effects:
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.
Contraindications:
asthma or other acute pulmonary disease
Side effects:
bronchospasm, pulmonary HTN, N/V/D, chills & shivering, HA, severe cramps, hot flashes/flushing.
Etiology
Weigh pads and chux:
1 mL blood = 1 gram
Lab Tests
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.
Volume restored within 24
hours without transfusion.
Class II: 750-1500 mL loss or 15-30%
of blood volume.
Needs IVF but not
necessarily transfusion.
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.
Full transcript