PPH Approach

– History –

  • CC:
    • Onset: when? First time? Sudden\gradual? Continuous\intermittent? Increasing\decreasing?
    • Characteristics: amount? Color? Clots? Tissue? Smell?
  • Associated sx:
    • Constitutional: fever, chills, appetite?
    • GI: N\V, abdominal pain?
    • Anemia: dizziness, syncope, headache, palpitations, SOB?
  • Quick important points:
    • Antepartum:
      • Gravida? Para? Abortions? Living?
      • Antenatal US: when? Findings?
      • Dx w\ any pregnancy conditions: GDM, anemia, pre-eclampsia
    • Peripartum:
      • Term\preterm?
      • Mode of delivery: vaginal, instrumental, C\S?
      • Needed episiotomy?
      • Labor: received oxytocin? Prolonged? PPROM?
      • Placenta previa, retained placenta?
      • Complications: trauma\lacerations
    • PMHx:
      • HTN, DM, bleeding ds, infections
      • Medications: anticoagulants
      • Previous surgeries, C\S, trauma, blood transfusion

 

– Physical Exam –

  • WIPE, blah blah, chaperone
  • Vital signs: pulse, BP, temperature
  • General inspection: pallor, confused, skin bruises\petechia
  • CVS, CNS, Resp exam: to assess hemodynamic status of the pt
  • Abdominal exam:
    • Tender: uterine rupture, retained placenta
    • Doughy soft uterus: uterine atony
  • Pelvic exam:
    • Inspect: vaginal lacerations or trauma
    • Speculum: cervical lacerations
    • Bimanual exam
  • Check placenta if it’s complete or missing portions!

 

– Investigations –

  • CBC, blood type, cross match, coagulation profile, chemistry (electrolyte, BUN\Cr), liver enzymes

 

– Management –

  1. Resuscitate and stabilize the pt -> ABCs! (focus on circulation)
  2. Treat underlying cause:
    • Uterine atony:
      1. Continuous bimanual uterine compression
      2. Uterotonic drugs: Oxytocin -> methylergonovine -> misoprostol -> carbopost tromethamine
      3. Methylergonovine is contraindicated in hypotension, Raynaud’s, scleroderma
      4. If failed medical Tx -> tamponade balloon, interventional radiology, surgery
    • Trauma:
      1. Thorough inspection of entire perineum and birth canal
      2. Analgesia
      3. Surgical repair
    • Tissue:
      1. Inject umbilical vein with 20 mL NS + 20 U oxytocin
      2. Analgesia
      3. Manual removal
    • Thrombin:
      1. Blood products replacement or transfusion (according to CBC and coagulation profile)

 


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