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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