Postpartum Hemorrhage Overview
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Postpartum Hemorrhage Overview

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Questions and Answers

What defines primary postpartum hemorrhage (PPH) in terms of blood loss after vaginal delivery and cesarean section?

Primary PPH is defined as bleeding in excess of 500ml after vaginal delivery or 1000ml after cesarean section within the first 24 hours.

What are the four main causes of primary postpartum hemorrhage referred to as the '4T's'?

The four main causes are Tone (uterine tone), Tissue (retained tissue), Trauma (lacerations), and Thrombin (bleeding disorders).

How does the presence of preexisting anemia affect a woman's tolerance to blood loss during postpartum hemorrhage?

Women with preexisting anemia have a decreased tolerance to blood loss compared to healthy women, who typically have an increased blood volume during pregnancy.

What percentage of pregnancy-related deaths worldwide is attributed to primary postpartum hemorrhage?

<p>Primary PPH accounts for 28% of pregnancy-related deaths worldwide.</p> Signup and view all the answers

List two factors that can contribute to uterine atony, a primary cause of postpartum hemorrhage.

<p>Prolonged or obstructed labor and over distention of the uterus, such as in polyhydramnios, can contribute to uterine atony.</p> Signup and view all the answers

Why is primary postpartum hemorrhage considered a major complication in both developed and developing countries?

<p>Primary PPH is a leading cause of maternal mortality, accounting for a significant portion of pregnancy-related deaths, especially in resource-limited settings.</p> Signup and view all the answers

What role does retained tissue play in the management of postpartum hemorrhage?

<p>Retained tissue, such as placental fragments, can lead to prolonged bleeding and is crucial to assess and treat in cases of PPH.</p> Signup and view all the answers

What is the estimated incidence range of primary postpartum hemorrhage?

<p>The estimated incidence of primary PPH ranges from 3.7% to 8.6%.</p> Signup and view all the answers

What is the condition characterized by abnormally adherent placenta, and what are the three types?

<p>Placenta accreta, placenta increta, and placenta percreta.</p> Signup and view all the answers

What is DIC and what are two conditions it is associated with?

<p>DIC stands for disseminated intravascular coagulation and is associated with placental abruption and amniotic fluid embolism.</p> Signup and view all the answers

List two preventive measures for postpartum hemorrhage (PPH).

<p>Correction of anemia and active management of the third stage of labor.</p> Signup and view all the answers

What is the preferred utero-tonic drug to administer immediately after the delivery of the baby?

<p>Oxytocin.</p> Signup and view all the answers

What is the Brandt-Andrews maneuver used for during labor?

<p>It is used for gentle cord traction with uterine counter-traction when the uterus is well contracted.</p> Signup and view all the answers

When should syntometrin be administered in relation to the delivery process?

<p>It should be given IM during the crowning of the fetal head.</p> Signup and view all the answers

What should be established upon recognizing a patient in need of immediate intervention during labor?

<p>At least 2 peripheral infusion lines using a wide bore cannula.</p> Signup and view all the answers

What is crucial to prepare while simultaneously restoring blood loss with IV fluids?

<p>Grouping and cross-matching 6 units of blood.</p> Signup and view all the answers

What are the initial steps to take if the uterus is lax after delivery?

<p>Perform uterine massage and administer utero-tonic drugs.</p> Signup and view all the answers

Describe the procedure for bimanual compression of the uterus.

<p>One hand forms a fist and is inserted into the vagina while the other hand compresses the abdomen to support the uterus.</p> Signup and view all the answers

What signs indicate that the placenta has separated from the uterus?

<p>A firm and rounded uterus at the level of the umbilicus and an elongated umbilical cord.</p> Signup and view all the answers

What should be avoided until after the placenta is manually removed?

<p>Avoid giving oxytocic drugs until after removal of the placenta.</p> Signup and view all the answers

Identify a common cause of uterine rupture during labor.

<p>Obstructed labor is a common cause of uterine rupture.</p> Signup and view all the answers

What factors can contribute to cervical lacerations during delivery?

<p>Forceps use on an undilated cervix and rapid delivery of the after-coming head in breech presentation.</p> Signup and view all the answers

What role do oxytocic drugs like ergometrin play after the delivery of the placenta?

<p>They help contract the uterus and prevent postpartum hemorrhage.</p> Signup and view all the answers

List two interventions used if the uterus remains soft and lax after the placenta is delivered.

<p>Uterine massage and intravenous administration of oxytocic drugs.</p> Signup and view all the answers

What is the timeframe for defining primary postpartum hemorrhage (PPH)?

<p>PPH is defined as excessive bleeding occurring within the first 24 hours after delivery.</p> Signup and view all the answers

What is the definition of secondary postpartum hemorrhage?

<p>Secondary PPH occurs after 24 hours and up to 6 weeks post-delivery.</p> Signup and view all the answers

What percentage of women die from pregnancy-related causes each year due to PPH?

<p>About 25% of the annual 500,000 pregnancy-related deaths are attributed to PPH.</p> Signup and view all the answers

What are common causes of uterine atony after delivery?

<p>Common causes include retained products of conception and prolonged obstructed labor.</p> Signup and view all the answers

How does the total blood volume change during normal singleton pregnancy?

<p>A healthy woman's blood volume increases by 30-50% during normal singleton pregnancy.</p> Signup and view all the answers

What condition can lead to abnormal uterine contraction post-delivery?

<p>General anesthesia used during operative delivery can cause relaxation of the myometrium.</p> Signup and view all the answers

What is the role of thrombin in the 4T's classification of PPH causes?

<p>Thrombin refers to bleeding disorders that can contribute to PPH.</p> Signup and view all the answers

What is a primary reason for uterine over distention during pregnancy?

<p>Over distention can occur due to conditions like polyhydramnios or multiple pregnancies.</p> Signup and view all the answers

What is one effective method for managing uterine atony?

<p>Uterine massage is an effective method for managing uterine atony.</p> Signup and view all the answers

What should be done if the uterus is soft and lax after the placenta is delivered?

<p>Manually remove any retained pieces of the placenta and administer oxytocic drugs.</p> Signup and view all the answers

What is the significance of a couvelaire uterus in relation to placental abruption?

<p>A couvelaire uterus signifies severe placental abruption, where blood infiltrates the uterine wall, possibly leading to significant complications.</p> Signup and view all the answers

What are two causes of uterine rupture during labor?

<p>Obstructed labor and improper use of oxytocic drugs are two causes of uterine rupture.</p> Signup and view all the answers

What is the purpose of bimanual compression of the uterus?

<p>Bimanual compression is used to compress the uterus to promote firmness and prevent hemorrhage.</p> Signup and view all the answers

What is the primary intervention for preventing postpartum hemorrhage (PPH) during the third stage of labor?

<p>Active management of the third stage of labor, which includes administering utero-tonic agents like oxytocin.</p> Signup and view all the answers

What are the three types of abnormally adherent placenta?

<p>Placenta accreta, placenta increta, and placenta percreta.</p> Signup and view all the answers

When should oxytocic drugs be avoided in relation to placenta removal?

<p>Oxytocic drugs should be avoided until after manual removal of the placenta.</p> Signup and view all the answers

What are two common associated conditions with DIC in the context of pregnancy?

<p>Placental abruption and amniotic fluid embolism.</p> Signup and view all the answers

What indicates that the placenta has separated from the uterus?

<p>A firm, rounded mass at the level of the umbilicus and an elongated umbilical cord indicate placental separation.</p> Signup and view all the answers

What is a common intervention if uterine atony does not resolve with initial measures?

<p>Uterine artery embolization is a common intervention for unresolved uterine atony.</p> Signup and view all the answers

What is the immediate management step during a suspected case of postpartum hemorrhage?

<p>Ensure that at least two peripheral intravenous lines are established.</p> Signup and view all the answers

What might signal a traumatic lesion in the genital tract if vaginal bleeding persists?

<p>If bleeding continues despite a contracted uterus, a traumatic lesion may be suspected.</p> Signup and view all the answers

What role does gentle cord traction with uterine counter-traction play postpartum?

<p>It aids in the expulsion of the placenta while ensuring uterine contraction.</p> Signup and view all the answers

What is a key pharmacological treatment to administer when managing high-risk patients for PPH?

<p>IV administration of oxytocin or ergometrin during the delivery of the anterior shoulder.</p> Signup and view all the answers

Why is it important to insert a urinary catheter in a postpartum hemorrhage scenario?

<p>It allows for accurate monitoring of urine output and assists in bladder management.</p> Signup and view all the answers

Study Notes

Postpartum Hemorrhage (PPH)

  • Definition: Excessive bleeding from the genital tract after childbirth.
  • Types:
    • Primary: Within the first 24 hours after delivery.
    • Secondary: After 24 hours and up to 6 weeks after delivery.
  • Classification: Based on the amount of blood loss:
    • Vaginal delivery: >500 ml
    • Cesarean section: >1000 ml
  • Incidence: 3.7 - 8.6%
  • Mortality: Major cause of maternal mortality worldwide, accounting for 28% of pregnancy-related deaths.

Causes of PPH

  • 4T's:
    • Tone: Uterine atony (ineffective contraction and retraction).
    • Tissue: Retained placental tissue or membranes.
    • Trauma: Lacerations or uterine rupture.
    • Thrombin: Bleeding disorders.

Uterine Atony

  • Causes of uterine atony:
    • Retained products of conception.
    • Prolonged or obstructed labor.
    • Operative delivery, especially with general anesthesia.
    • Uterine overdistension (e.g., polyhydramnios, multiple pregnancy).
    • Large placental site.
    • Placenta previa.
    • Abruptio placenta.
    • Multiparity.
    • Uterine fibroids.
    • Full bladder.

Abnormally Adherent Placenta

  • Types:
    • Placenta accreta: Partial attachment to the uterine wall.
    • Placenta increta: Invasion into the uterine myometrium.
    • Placenta percreta: Penetration through the uterine wall.

Clotting Disorders

  • Hereditary blood disorders.
  • Disseminated Intravascular Coagulation (DIC): Associated with placental abruption, amniotic fluid embolism, and intrauterine death.

Prevention of PPH

  • Correcting anemia.
  • Active management of the third stage of labor:
    • Uterotonic administration (e.g., oxytocin).
    • Early cord clamping and cutting.
    • Gentle cord traction with uterine counter-traction (Brandt-Andrews maneuver).

Management of PPH

  • Call for help and follow ABCs (airway, breathing, circulation).
  • Establish two peripheral intravenous lines with large bore cannulas (gauge 14).
  • Prepare 6 units of cross-matched blood (preferably fresh whole blood).
  • Monitor vital signs and central venous pressure (CVP).
  • Replace blood loss with IV fluids (e.g., Hartmann's solution, Hetastarch) until cross-matched blood is available.
  • Insert a urinary catheter.

Management of Specific Causes of PPH

  • Uterine Atony:
    • Uterine massage.
    • Bimanual compression of the uterus.
    • Intrauterine balloon tamponade.
    • Uterine packing.
    • Uterine artery embolization.
    • Uterine artery ligation.
    • B-Lynch suture.
  • Trauma:
    • Transfer to the operating room under anesthesia.
    • Inspect the genital tract for lacerations.
    • Remove any retained placental tissue.

Management of Placental Separation

  • Signs of placental separation:
    • Uterus firm, rounded mass at the level of the umbilicus.
    • Uterine mobility.
    • Elongated umbilical cord.
    • Part of the placenta in the vagina.
  • If no signs of placental separation, it should be removed manually under anesthesia.

Management of Uterine Rupture

  • Causes:
    • Previous uterine surgeries (e.g., cesarean section, myomectomy).
    • Obstructed labor.
    • Forceps delivery.
    • Misuse of oxytocin.
    • Multiparity.
  • Complete or incomplete rupture.

Management of Cervical Lacerations

  • Causes:
    • Precipitated labor.
    • Forceps delivery on an undilated cervix.
    • Rapid delivery in breech presentation.
    • Previous cervical injury.

Postpartum Hemorrhage (PPH)

  • Definition: Excessive bleeding from the genital tract after childbirth.
  • Types:
    • Primary PPH: Within the first 24 hours after delivery.
    • Secondary PPH: After 24 hours up to six weeks after delivery.
  • Classification:
    • Primary PPH: Bleeding exceeding 500ml after vaginal delivery or 1000ml after Cesarean section (C-section) within the first 24 hours.
    • Secondary PPH: Defined by a 10% drop in hematocrit value.
  • Incidence: 3.7-8.6% of deliveries.
  • Mortality: PPH accounts for 28% of pregnancy-related deaths globally.
  • Contributing factors:
    • Preexisting conditions: Anemia, cardiac issues, dehydration, preeclampsia.
    • Developing countries: Higher maternal mortality rates due to limited access to healthcare.
  • Causes: Using the mnemonic "4T"
    • Tone: Uterine atony (lack of uterine contraction).
    • Tissue: Retained placental tissue or membranes.
    • Trauma: Lacerations in the cervix or vagina, uterine rupture.
    • Thrombin: Bleeding disorders.

Uterine Atony

  • Causes:
    • Prolonged or obstructed labor.
    • Operative delivery (especially with general anesthesia).
    • Overdistention of the uterus (polyhydramnios, multiple pregnancies).
    • Large placental site (multiple pregnancies).
    • Placenta previa.
    • Abruptio placenta.
    • Multiparity.
    • Uterine fibroids.
    • Full bladder.
    • Couvelaire uterus (blue discoloration of the uterus).

Abnormally Adherent Placenta

  • Types:
    • Placenta accreta: Placenta attaches to the uterine wall.
    • Placenta increta: Placenta invades the uterine wall.
    • Placenta percreta: Placenta penetrates the uterine wall and may involve surrounding organs.

Clotting Disorders

  • Causes:
    • Hereditary bleeding disorders.
    • Disseminated Intravascular Coagulation (DIC).
    • Associated with: placental abruption, amniotic fluid embolism, intrauterine death (IUD), and retained dead fetus.

Prevention

  • Strategies:
    • Correction of anemia.
    • Active management of the third stage of labor:
      • Uterotonic drugs (primarily oxytocin) administered immediately after baby delivery.
      • Early cord clamping and cutting.
      • Gentle cord traction with uterine countertraction (Brandt-Andrews maneuver).
    • Identify high-risk patients: Those with a previous history of PPH.

Management

  • Immediate actions:

    • Establish two peripheral IV lines with large bore cannulas.
    • Blood grouping and cross-matching: Prepare at least six units of fresh whole blood.
    • Assess vital signs and central venous pressure (CVP).
    • Fluid resuscitation: Use Hartmann's solution or hemacel until cross-matched blood is available (group O- blood can be used temporarily).
    • Insert a urinary catheter.

  • Identify and address the underlying cause:

    • Uterine Atony: Palpate the uterus, administer uterotonic drugs, uterine massage, bimanual compression of the uterus, intrauterine balloon, uterine packing, uterine artery embolization, uterine artery ligation, internal iliac artery ligation, B-Lynch suture.
    • Trauma:
      • Placenta delivered and uterus contracted: Transfer to the operating room for examination under anesthesia.
      • Placenta delivered and uterus soft and lax: Uterine massage and administer oxytocic drugs intravenously (ergometrin 0.5mg and oxytocin infusion).
      • Placenta not delivered: Signs of placental separation (uterus firm, rounded, moves from side to side, umbilical cord elongates, part of the placenta felt in the vagina). Manual removal of the placenta under general anesthesia after stabilization of the patient.
    • Traumatic lesions of the genital tract:
      • Uterine rupture: May occur during pregnancy, labor, or due to previous surgery (classical C-section, myomectomy).
      • Cervical lacerations: Precipitated labor, forceps delivery on an undilated cervix, breech delivery of the aftercoming head.

Additional Notes

  • Brandt-Andrews maneuver: Gentle controlled traction on the umbilical cord with counterpressure on the uterus.
  • Couvelaire uterus: A rare condition where blood pools under the uterine lining, causing bruising.
  • Oxytocin: A synthetic hormone that stimulates uterine contractions.
  • Ergometrine: A medication that constricts blood vessels and stimulates uterine contractions.

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Description

This quiz covers the crucial aspects of postpartum hemorrhage (PPH), including its definition, types, causes, and classification. Key factors such as uterine atony and the 4T's leading to PPH are explored in detail to enhance your understanding of this important maternal health issue.

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