POST-NATAL CARE
Post-Partum Haemorrhage (PPH)
Definition Risk factors Preventative measures
Ø Primary PPH: blood loss > 500ml (NVD) or > 1000mL Maternal issue 2/3rd of primary PPH cannot be predicted
(LSCS) in 1st 24 hrs Ø Previous PPH
Ante-natal
Ø Severe PPH: blood loss > 1000ml Ø Obesity
Ø Secondary PPH = PPH b/w 24 hrs and 6 wks Ø Pre-eclampsia Ø Treat anaemia
Ø Major obstetric haemorrhage Ø Multi-pregnancy Ø Empty bladder prior to birth (full bladder reduces contraction)
o blood loss > 2500ml Placental issue
o require transfusion > 5 units red cells Ø Placental abruption
Ø Placental accrete Peri-natal
Ø Primary within 24h birth or secondary 24h → 6w
Foetal issue 1. Prophylactic 10U IM syntocinon (once anterior shoulder seen)
Ø Large baby 2. Cord clamp + placenta delivery (support fundus and identify
Remember: Delivery itself signs of placental separation)
Ø Maternal blood volume » 7L Ø Failure to progress
Ø Blood loss of > 30% (2.1L) è critical 3. IV TXA (in high risk LSCS patients)
Ø Instrumental delivery
Ø Placenta 600-700mL blood loss/min Ø GA
Ø Episiotomy
Active Mx of PPH
Listen and clarify handover [patients may NOT present classically]
How to stop the bleed – pharmacotherapy - uterotonics?
Ø Turn lights on
1) Ø Elicit concerns – where is baby? Any complications w/ delivery? *CONTINUE uterine massage
o Ask how they are feeling? – SOB, light-headed?
Ø Obtain ante-natal card
1st line = increase uterine contraction
Recognise ED ® SEND FOR HELP
• Check vitals (↑HR, ↑RR, ↓sats, ↓BP) 1. 250µg ergometrine IM or Ergometrine = arterial A/E = HTN, chest pain,
2) • EBL (weigh pads + swabs) slow IV injection vasoconstriction and palpitations, raynaud’s
AND/OR myometrial contraction CI: pre-eclampsia, HTN
• Palpate fundus (?boggy) + inspect vulva + placenta
Request PPH box + notify blood bank IV 40U syntocinon (500mL ) ↑ uterine tone and A/E: N/V. headache
3) 2.
infusion myometrial contraction
4) Lie Patient FLAT + keep patient warm
2nd line = Reduce blood loss due to atony if 1st line unsuccessful (exclude other causes)
A - patent
Rule of 30’s: 4.
800µg misoprostol (PR) Pg analogue → A/E: anaphylaxis, abdo
B – high FiO2 contraction pain, diarrhoea
C – 2x large bore 16G cannulas [critical] Ø HR ↑30 IM 250µg Carboprost Pg analogue → A/E: high fever, light-
• Bloods = FBC, Coags, Group + X-match Ø EBL > 30%
5) (ask for O negative for blood bank)
5. (every 15 mins – 8x doses) contraction headed, SOB
Ø SBP ↓30 CI: HTN, asthma
• IVF – warm 2L Hartman’s
Ø Hct/Hb ↓30 IV 1g TXA in 100mL ns anti-fibrinolytic → Clotting –
• Insert IDC – reduce bladder volume + 6.
measure UO prevents clot breakdown PE/Stroke/AMI
Identify causes Activate MTP By senior 4x pRBC SEE GUIDELINES
7. clinician è Hb < 70
5) Ø Continue Baseline Obs 2x FFP
Ø Weigh linen pads ® estimate blood loss Surgery – bakri balloon tamponade (PRESS against bleeding)
RF Cause Specific Mx 8. • B-lynch suture (suture uterus to compress it)
• Uterine artery embolization
Overdistension • Hysterectomy (last resort)
Ø atonic uterus
Ø Poly, macro, prolong
Ø Multi-gest, fibroids
Ø uterine Ø Uterine fundal Care after PPH:
exhaustion massage
Maternal 1) Beware of 2nd PPH (24 hrs to 12 wks post-partum) è retained POC or infection
Tone (70%) Ø precipitous Ø LOOK for what
Ø Advanced age delivery comes out – clots,
(endometritis)
Ø BMI >35 blood? a. USS (visualise retained POC) or high vag swabs (infection)
Ø drugs (GA,
Ø Hx of APH, PPH
MgSO4) b. Surgical removal of POC OR antibiotics if infection
Ø IoL, instrumental
2) CVS – vitals, fundal tone, weigh pads, DIC (bleed + clots)
Ø Precipitous bith
Ø Instrumental Ø vaginal / cervix Inspect genital tract ® a. Check fluid intake + urine output
Trauma
/ perineal lacerations 3) Resp – RR, sats, LOC
(19%) Ø Episiotomy lacerations haematomas
Ø LSCS 4) Renal – fluid restriction, haematuria, oliguria
Ø retained 5) Patho- FBC, EUC, LFT, coags
Ø retained placenta
Tissue placenta, Assess placenta and 6) Psych Support – depression, social support
Ø placenta accrete
(10%) membrane or membranes
Ø Manual removal clots
7) Exercise + Ted Stockings, mobilise
Ø pre-eclampsia
Thrombin DIC or VWF, ↓plt MTP + ROTEM
(1%) Ø amniotic fluid
Coag defects • plt, FFP, cryoppt
embolism
, O+G Abnormal Early Pregnancy Presentations
Blood products:
1) Group and X-
match (pink-
hand-labelled
tube)
2) Whole blood
(RBC, WCC, plt)
3) pRBC =severe
anaemia (Hb <70)
4) plt = <10
5) cryoppt = clot
factors
(fibrinogen def,)
6) FFP (albumin +
cryoppt) = correct
factor def of
hypovol. Shock
Post-Partum Haemorrhage (PPH)
Definition Risk factors Preventative measures
Ø Primary PPH: blood loss > 500ml (NVD) or > 1000mL Maternal issue 2/3rd of primary PPH cannot be predicted
(LSCS) in 1st 24 hrs Ø Previous PPH
Ante-natal
Ø Severe PPH: blood loss > 1000ml Ø Obesity
Ø Secondary PPH = PPH b/w 24 hrs and 6 wks Ø Pre-eclampsia Ø Treat anaemia
Ø Major obstetric haemorrhage Ø Multi-pregnancy Ø Empty bladder prior to birth (full bladder reduces contraction)
o blood loss > 2500ml Placental issue
o require transfusion > 5 units red cells Ø Placental abruption
Ø Placental accrete Peri-natal
Ø Primary within 24h birth or secondary 24h → 6w
Foetal issue 1. Prophylactic 10U IM syntocinon (once anterior shoulder seen)
Ø Large baby 2. Cord clamp + placenta delivery (support fundus and identify
Remember: Delivery itself signs of placental separation)
Ø Maternal blood volume » 7L Ø Failure to progress
Ø Blood loss of > 30% (2.1L) è critical 3. IV TXA (in high risk LSCS patients)
Ø Instrumental delivery
Ø Placenta 600-700mL blood loss/min Ø GA
Ø Episiotomy
Active Mx of PPH
Listen and clarify handover [patients may NOT present classically]
How to stop the bleed – pharmacotherapy - uterotonics?
Ø Turn lights on
1) Ø Elicit concerns – where is baby? Any complications w/ delivery? *CONTINUE uterine massage
o Ask how they are feeling? – SOB, light-headed?
Ø Obtain ante-natal card
1st line = increase uterine contraction
Recognise ED ® SEND FOR HELP
• Check vitals (↑HR, ↑RR, ↓sats, ↓BP) 1. 250µg ergometrine IM or Ergometrine = arterial A/E = HTN, chest pain,
2) • EBL (weigh pads + swabs) slow IV injection vasoconstriction and palpitations, raynaud’s
AND/OR myometrial contraction CI: pre-eclampsia, HTN
• Palpate fundus (?boggy) + inspect vulva + placenta
Request PPH box + notify blood bank IV 40U syntocinon (500mL ) ↑ uterine tone and A/E: N/V. headache
3) 2.
infusion myometrial contraction
4) Lie Patient FLAT + keep patient warm
2nd line = Reduce blood loss due to atony if 1st line unsuccessful (exclude other causes)
A - patent
Rule of 30’s: 4.
800µg misoprostol (PR) Pg analogue → A/E: anaphylaxis, abdo
B – high FiO2 contraction pain, diarrhoea
C – 2x large bore 16G cannulas [critical] Ø HR ↑30 IM 250µg Carboprost Pg analogue → A/E: high fever, light-
• Bloods = FBC, Coags, Group + X-match Ø EBL > 30%
5) (ask for O negative for blood bank)
5. (every 15 mins – 8x doses) contraction headed, SOB
Ø SBP ↓30 CI: HTN, asthma
• IVF – warm 2L Hartman’s
Ø Hct/Hb ↓30 IV 1g TXA in 100mL ns anti-fibrinolytic → Clotting –
• Insert IDC – reduce bladder volume + 6.
measure UO prevents clot breakdown PE/Stroke/AMI
Identify causes Activate MTP By senior 4x pRBC SEE GUIDELINES
7. clinician è Hb < 70
5) Ø Continue Baseline Obs 2x FFP
Ø Weigh linen pads ® estimate blood loss Surgery – bakri balloon tamponade (PRESS against bleeding)
RF Cause Specific Mx 8. • B-lynch suture (suture uterus to compress it)
• Uterine artery embolization
Overdistension • Hysterectomy (last resort)
Ø atonic uterus
Ø Poly, macro, prolong
Ø Multi-gest, fibroids
Ø uterine Ø Uterine fundal Care after PPH:
exhaustion massage
Maternal 1) Beware of 2nd PPH (24 hrs to 12 wks post-partum) è retained POC or infection
Tone (70%) Ø precipitous Ø LOOK for what
Ø Advanced age delivery comes out – clots,
(endometritis)
Ø BMI >35 blood? a. USS (visualise retained POC) or high vag swabs (infection)
Ø drugs (GA,
Ø Hx of APH, PPH
MgSO4) b. Surgical removal of POC OR antibiotics if infection
Ø IoL, instrumental
2) CVS – vitals, fundal tone, weigh pads, DIC (bleed + clots)
Ø Precipitous bith
Ø Instrumental Ø vaginal / cervix Inspect genital tract ® a. Check fluid intake + urine output
Trauma
/ perineal lacerations 3) Resp – RR, sats, LOC
(19%) Ø Episiotomy lacerations haematomas
Ø LSCS 4) Renal – fluid restriction, haematuria, oliguria
Ø retained 5) Patho- FBC, EUC, LFT, coags
Ø retained placenta
Tissue placenta, Assess placenta and 6) Psych Support – depression, social support
Ø placenta accrete
(10%) membrane or membranes
Ø Manual removal clots
7) Exercise + Ted Stockings, mobilise
Ø pre-eclampsia
Thrombin DIC or VWF, ↓plt MTP + ROTEM
(1%) Ø amniotic fluid
Coag defects • plt, FFP, cryoppt
embolism
, O+G Abnormal Early Pregnancy Presentations
Blood products:
1) Group and X-
match (pink-
hand-labelled
tube)
2) Whole blood
(RBC, WCC, plt)
3) pRBC =severe
anaemia (Hb <70)
4) plt = <10
5) cryoppt = clot
factors
(fibrinogen def,)
6) FFP (albumin +
cryoppt) = correct
factor def of
hypovol. Shock
