Postpartum Hemorrhage

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Author:
JMC
ID:
266119
Filename:
Postpartum Hemorrhage
Updated:
2014-03-12 09:53:56
Tags:
Postpartum hemorrhage
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Description:
Postpartum hemorrhage NM 622
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  1. PPH Definition
    • >500 ml in vaginal birth
    • >1000 ml in CS
    • Hct drop of >10pts
  2. Risk factors for PPH
    • Prolonged labor
    • Rapid labor
    • Macrosomia
    • Multiples
    • Polyhydramnios
    • Hx PPH, uterine atoony
    • Induction/augmentation
    • Chorio
    • MgSo4 in Labor
    • General antesthesia
  3. 3rd Stage Hemorrhage
    Definition and cause
    • Occurs during after birth and before placental expulsion
    • #1 cause is mismanagement = partial separation
    • RARE if managed properly
    • Other causes: infection, previous CS, disease process of fetal membranes
  4. Management of 3rd Stage Hemorrhage
    • CALL MD!!!  
    • TIME CRITICAL!!!
    • Thoroughly massage uterus (the only time this is done with placenta still attached!)
    • IV, type & cross, treat shock
    • Oxytocin 20-40 units/1000ml NS or LR (if not used yet)
    • Methergine .02 mg IM
    • Hemabate 250 mcg IM with Lomotil & Zofran

    • Manual removal of placenta (Varney 4th p.1269)
    • IU exploration PRN
  5. Signs & Symptoms of Shock
    • Hypotension
    • Tachycardia
    • Tachypnea
    • Shallow breaths
    • Cool/clammy skin
  6. Treatment of Shock
    • Trendelenberg
    • O2
    • Warm blankets
    • Order blood
    • IVF
  7. 4th Stage Hemorrhage
    Definition and Cause
    • "Immediate PPH"
    • After birth of placenta
    • Causes: 80-90% due to atony (overdistention, long labor, rapid labor, oxytocin for i/a, multiparity, Hx PPH/atony, MgSo4, nifedipine, terubutaline)
    • Also: retained fragments, placenta accreta, coagulopathies
  8. Management of 4th Stage/Immediate PPH
    • ***CHECK UTERINE TONE***
    • Call MD
    • Bimanual compression with continued bleeding
    • Oxytocin (if not used yet)
    • - methergine or hemabate if oxy used; not Cytotec - no more effective than oxytocin - may be less effective; has negative side effects
    • Continue BM compression
    • Examine placenta for completeness
    • IU exploration PRN
    • Monitor for shock
  9. Oxytocin for PPH
    • First line therapy
    • 20-40 units in 1000ml IVF
    • 10 units IM if no IV available
  10. Contraindications to Oxytocin use
    NEVER give UNDILUTED bolus
  11. Side effects of Oxytocin
    • Cramping
    • Hyponatremia
  12. Methergine for PPH
    • 2nd line therapy
    • α-adrenergic agonist
    • 0.2 mg IM
  13. Contraindications for Methergine
    HTN
  14. Side effects of Methergine
    • N/V/D
    • Cramping
    • HTN
    • Seizure
    • HA
  15. Hemabate for PPH
    • Also 2nd line treatment
    • 250 mcg IM
  16. Contraindications for Hemabate
    • Asthma
    • Heart, liver, kidney, pulmonary disease
  17. Side effects of Hemabate
    • Extreme N/V/D - give with lomotil, zofran
    • Fever
  18. Misoprostol for PPH
    Latest research shows no better at treating PPH, may have worse side effects
  19. Side effects of Misoprostol
    • Diarrhea
    • Abdominal pain
    • Severe shivering/shaking

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