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Microsoft powerpoint - post partum haemorrhage [compatibility mode]

Post Partum Haemorrhage Darent Valley Hospital
Risk Factors/Etiology Communication, Resuscitation, Monitoring & Ix, Arresting the bleeding, drugs used Patients who refuse blood How to survive your first PPH

PREVENTION AND MANAGEMENT OF POSTPARTUM HAEMORRHAGE
Major cause of maternal death and morbidity despite a fall in number in this triennium
In the UK major obstetric haemorrhage is 3.7/1000
50% of the 500 000 maternal death globally is due to
All units should have protocols in place for its identification and
CMACE 2006-08 9 deaths 0.39/100 000
Majority of these considered preventable
Obstetric haemorrhage encompasses antepartum and
APH often associated with subsequent PPH Volume 118, Supplement 1, March 2011 BJOG An International
Journal of
Obstetrics and Gynaecology
Saving Mothers' Lives
Reviewing maternal deaths to make
motherhood safer: 2006–2008
March 2011
The Eighth Report of the Confidential
Enquiries into Maternal
Deaths in the United Kingdom
 2 -Pre-eclampsia and  3 -Thromboembolism (18)  4- Amniotic fluid embolism  5- Early pregnancy deaths  6 -Haemorrhage (9) Loss of >500 ml blood from genital tract within 24h of birth of baby Minor (500-1000ml) Major (>1000ml) Moderate 1000-2000ml Severe >2000ml Abnormal/excessive bleeding from birth canal between 24h and 12/52 postnatally All PPH are audited and reported on a monthly basis International definition of PPH not unified:
Traditional WHO definition of primary PPH encompasses all blood losses > 500ml
Est loss >1000ml appropriate cut off for major PPH and initiation of emergency protocol measures other 1500ml
Estimations of blood volume based on weight (weight kg/12)
Allowing for physiological increase in pregnancy blood vol at
Blood loss of >40% (approx 2800ml) total bld vol : ‘life-
Consideration of antenatal Hb (<11g/dl Ix and Rx pre delivery)
Evidence that iron-def anaemia assoc with atony secondary to depleted uterine myoglobin levels (needed for muscle action)
Visual blood loss estimates often underestimate true loss Risk Factors for PPH Most cases of PPH have no identifiable risk factors however the following increase the risk of PPH: Four T's (Society of Obs and Gynae of Canada) Lacerations, uterine rupture Retained products Coagulation disorders

Regular skill drills Monitoring & Investigation Arresting the bleeding
Basic measures for minor PPH (500-1000ml)  Alert midwife-in-charge  Alert first-line obstetric and anesthetic staff
Full protocol for major PPH  Call experienced midwife (in addition to midwife in charge)  Declare "code blue"  Call obstetric middle grade and alert consultant  Call anaesthetic middle grade and alert consultant  Alert consultant clinical haematologist on callIf no code blue in place Alert blood transfusion laboratory  Call porters for delivery of specimens/bloodOne member of the team designated to record events, fluids, drugs and vital signs QuickTime™ and a are needed to see this picture.

Assess A, B, C
O2 10-15l/min
IV access (14G x2)
Position flat
Patient warming blanket
Transfuse PRC ASAP
Until available infuse up to 3.5l: of warmed crystalloid: Hartmann's solution 2l +/- colloid 1-2l as rapidly as required
Use best device available to achieve RAPID WARMED infusion of fluids (eg level 1 rapid infusor)
Special blood filters should NOT be used acutely - slow
Recombinant factor VIIa therapy should be based on the results of coagulation (Protocol) up to 2L Hartmann's or Plasmalyte up to 1-2L of colloid until the blood products
Cell salvage if possible In an organised way, "Code Blue" to contract the uterus to help the coagulation

2006 guideline from British Committee for Standards in Haematology - main therapeutic goals of management of massive blood loss is to maintain:  PLT count > 75 x 10 9/l  PT <1.5 x mean control  APTT < 1.5 x mean control  Fibrinogen > 1.0 g/l Monitoring & Investigation  X match if not already done(4 u min), FBC, Coagulation (incl Fib), U&Es, LFTs
Monitor temperature every 15 min
Continuous pulse, BP recording and RR (oximeter, ECG, NIBP)
Foley catheter for UO monitoring
2 x 14/16G cannulae
Consider IABP
Consider transfer to ICU once bleeding controlled/ monitoring on obstetric HDU if appropriate
TRALI
Record parameters on HDU or equivalent chart
Documentation of fluid balance, blood, blood products and How to stop the bleeding
Causes for PPH may be considered to relate to one of the 4 Ts  Tone, tissue, trauma, thrombin
Most common cause of primary PPH is uterine atony
Clinical examination necessary to exclude other causes:  Retained products (placenta, membranes, clots)  Vaginal/cervical lacerations or haematoma  Ruptured uterus  Broad ligament haematoma  Extragenital bleeding (for example, subscapular liver  Uterine inversion Uterine Atony: a team effort
Bimanual uterine compression (rubbing up the fundus) to stimulate contractions
Ensure bladder is empty (Foley catheter)
Syntocinon 5 u by slow IV injection (may have repeat dose)
Ergometrine 0.5mg by slow IV/IM injection (C/I in HTN)
Syntocinon infusion (40u in 500ml @ 125ml/hr) or in 50mls if
Carboprost 0.25mg IM injection repeated at intervals of not less than 15min to max of 8 doses (C/I in asthma)
Direct intramyometrial injection of carboprost 0.5mg (C/I in asthma - responsibility with administering clinician as not recommended for intramyometrial use)
Misoprostol 1000mcg PR Surgical Haemostasis
Intrauterine balloon tamponade
Haemostatic brace suturing (B Lynch suture) delayed suture (>2h) increases the rate of hysterectomy
Bilateral ligation of uterine arteries
Bilateral ligation of internal iliac arteries
Selective arterial embolisation
Resort to hysterectomy SOONER RATHER THAN LATER (esp if placenta accreta or uterine rupture)
UKOSS 40.6/100 000 hysterectomies to control haemorrhage
39% morbidly adherent placenta, main cause previous LSCS Drugs to help the coagulation
Tranexamic acid
Recombinant Factor VIIa Management of major PPH
All women who have had a previous LSCS must have their placental site determined.

Identify women "at risk" and be prepared.

Women delivered by LSCS must have regular obs recorded on the MEOWS chart for the first 24hrs.

RCOG recommend that women with major placenta praevia who have previously bled should be admitted and managed as in patients from 34/40
All clinicians should be aware of the guidelines for management of women who refuse blood.
Jehovah's Witness Optimise Hb during pregnancy, oral iron, IV iron, folic acid, recombinant human erythropoietin.
Advance directives from hospital and JW Hospital Committee Anaesthetic clinic Plan delivery as much as possible Same management as any PPH but without being able to give blood.
Inform the consultant anaesthetist Alert the consultant haematologist early.
Recombinant factor VIIa Prothrombin complex concentrate Beriplex Increase the dose of syntocinon, ensure good uterine contraction.
How to survive your first PPH
Do not panic, think ABC
Do not join in the mass hysteria
Call for help i.e. consultant and senior
If in doubt always declare a code blue
Beware of hidden blood loss
Be ahead of the game
Be assertive and ensure adequate

Source: http://www.odpskills.co.uk/pdf/pph.pdf