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JMC
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PPH Definition
- >500 ml in vaginal birth
- >1000 ml in CS
- Hct drop of >10pts
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Risk factors for PPH
- Prolonged labor
- Rapid labor
- Macrosomia
- Multiples
- Polyhydramnios
- Hx PPH, uterine atoony
- Induction/augmentation
- Chorio
- MgSo4 in Labor
- General antesthesia
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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
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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
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Signs & Symptoms of Shock
- Hypotension
- Tachycardia
- Tachypnea
- Shallow breaths
- Cool/clammy skin
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Treatment of Shock
- Trendelenberg
- O2
- Warm blankets
- Order blood
- IVF
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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
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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
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Oxytocin for PPH
- First line therapy
- 20-40 units in 1000ml IVF
- 10 units IM if no IV available
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Contraindications to Oxytocin use
NEVER give UNDILUTED bolus
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Methergine for PPH
- 2nd line therapy
- α-adrenergic agonist
- 0.2 mg IM
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Contraindications for Methergine
HTN
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Side effects of Methergine
- N/V/D
- Cramping
- HTN
- Seizure
- HA
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Hemabate for PPH
- Also 2nd line treatment
- 250 mcg IM
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Contraindications for Hemabate
- Asthma
- Heart, liver, kidney, pulmonary disease
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Side effects of Hemabate
- Extreme N/V/D - give with lomotil, zofran
- Fever
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Misoprostol for PPH
Latest research shows no better at treating PPH, may have worse side effects
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Side effects of Misoprostol
- Diarrhea
- Abdominal pain
- Severe shivering/shaking
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