Birth Emergency Skills Training

Report
Birth Emergency Skills Training
Postpartum Hemorrhage
Written and Illustrated by
Bonnie U. Gruenberg, CNM, MSN, CRNP, EMT-P
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Postpartum Hemorrhage
• Cause of most maternal
morbidity and mortality
worldwide.
• Can lead to shock, renal
failure, acute respiratory
distress syndrome,
coagulopathy, Sheehan's
syndrome, or death.
Postpartum Hemorrhage
Defined variously as
• Symptomatic bleeding
• EBL 500 ml after vaginal birth or
1,000 ml after cesarean
• 10% decline in postpartum
hemoglobin levels.
In truth, PPH is best defined by
clinician who decides blood loss
is enough to warrant intervention.
Risk Factors for PPH
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Prior PPH
Uterine over-distention
Shoulder dystocia
Prolonged labor
Episiotomy
Instrumented delivery
Be prepared for PHH at every delivery
Hemorrhage?
Get on TRAC:
What causes hemorrhage?
• T TRAUMA (20%)
• R RETAINED products (10%)
• A ATONY (>70%)
• C COAGULATION defects (1%)
Expectant
Third Stage Management
• Wait for placenta to
separate.
• Leave cord intact
until stops pulsing.
• Oxytocin or baby to
breast after
placenta delivers.
Active Third Stage
Management
• Oxytocin with delivery of
anterior shoulder or baby (or
sometimes after placenta).
• Cord clamping early (30 sec)
or delayed (45-90 sec).
• Controlled cord traction.
• Uterine massage after
placenta.
Active 3rd Stage management
encouraged
• Recommended by
obstetrical and
midwifery
organizations
worldwide.
• Shortens third stage,
decreases PPH, does
not increase retention
of placenta.
Timing of Cord Clamping
• Research now supports delayed
cord clamping (45-90 sec).
– Decreases anemia in both full
and preterm infants.
– Decreases brain hemorrhage
and respiratory distress
syndrome in preterm infants.
– Less risk of fetomaternal
transfusion.
Controlled Cord Traction
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Clamp cord near introitus.
Watch for signs of detachment.
Grasp uterus just above the symphysis.
With contraction, exert pressure upward and
backwards.
Encourage mother to push.
Apply careful downward and backwards
traction to cord.
Tension initially light, gradually increased.
If the placenta does not deliver after 30–40
seconds, wait for next contraction, repeat.
Aggressive cord traction can cause uterine
inversion or cord avulsion.
Bleeding with placenta
undelivered?
• Use controlled cord
traction and Brandt
Andrews maneuver.
• May give IV/IM
oxytocin before
placenta is out–
doesn’t cause
retained placenta.
• May inject umbilical
vein with 20 ml of a
0.9% saline
containing 20–40 u
of oxytocin.
Manual Removal of Placenta
If placenta not easily delivered or cord is
avulsed:
– Allow uterus to relax, insert hand.
– Control fundus with opposite hand.
– Remove placenta if it is in the lower
segment.
– Seek placental edge.
– Use hand as a spatula, insert
fingers into cleavage plane
between placenta and uterus.
– Gather placenta in your palm,
remove intact.
– If unsuccessful, transport for
surgical removal.
Uterine Atony
• Most PPH due to uterine atony.
• Assess tone while massaging uterus
through abdominal wall.
• Give oxytocin 20–40 units in 1 liter of
NS at 10–15 ml/min rapidly, or 10
units IM.
• Empty bladder with catheter.
• Express clots or manually remove
clots from the vagina, cervix, and
lower uterine segment.
Grasp the uterus through the abdominal wall
with your two hands and knead firmly.
Bimanual Compression
for Uterine Atony
• Insert entire hand in the vagina, in
the anterior fornix and make a fist.
• Grasp fundus with your other hand
and bend it onto the fist that is
inside vagina.
• Compress uterus between your
hands to remove clots and
stimulate contraction.
Bimanual Compression
• 10 minutes of compression
usually decreases bleeding
even if atony persists.
• May control bleeding from
ruptured uterus.
• Alternatively, may grasp uterus
with hands through abdomen
and compress for 10 minutes.
Aortic Compression
• Useful if hemorrhage is severe and
hospital is distant.
• Place fist on maternal abdomen with
index finger at umbilicus and knuckles
in line with spine.
• Compress aorta against spine. You will
feel pulse under your fist.
• Palpate for femoral pulse with your
opposite hand. Compress until the
femoral pulse disappears.
• If womans’s legs become tingly, release
pressure to allow some perfusion, then
resume.
Medications: Ergot alkaloids
• Methylergonovine (Methergine),
ergometrine, and ergonovine
cause tetanic uterine contraction.
• Give 0.2 mg IM, may repeat q 2–
4 h.
• May cause nausea and vomiting,
hypertension .
• Contraindications: Hypertension
and preeclampsia .
Prostaglandins
• IM carboprost (Hemabate) 250 mcg
repeat q 15 m to max 8 doses.
– Vasoconstricts and stimulates
contraction.
– Side effects include vomiting,
diarrhea.
– Use with caution in asthma and
hypertension.
• Misoprostil
– Up to 1,000 mg rectally, 200 mcg
orally. For prevention 600 orally
postpartum.
– Side effects fever, nausea, and
diarrhea.
Retained Tissue
• Inspect the placenta for missing
fragments or lobes.
• If hemorrhage continues despite
compression and uterotonics, enter
uterus to remove clots, membrane,
and retained tissue.
• Try wrapping gauze around one hand
and gently sweeping uterus.
• Adherent placental fragments may
require D&C in hospital.
Examine for missing fragments
A succenturiate lobe may remain in the uterus after the rest
of the placenta delivers, causing hemorrhage.
Tissue Trauma
• Likely if bleeding persists despite
well-contracted uterus.
• Inspect genital tract from
perineum to cervix.
• Palpate uterine cavity for
evidence of uterine rupture.
• Apply pressure to bleeding
laceration - suture the wound if
direct pressure does not stop
bleeding.
Cervical Lacerations
– Insert a speculum.
– Grasp anterior cervix with ring forceps.
– Place a second ring forceps at the 2o'clock position, and systematically
place one forceps ahead of the next,
proceeding around the circumference.
– Suture cervical lacerations only if they
are actively bleeding.
– If you cannot find apex, place stitch high
and sew proximally, using traction on
suture line to pull apex into view.
Hematomas
• May occur with or without
laceration.
• Causes intense pain and
localized, tender swelling,
tachycardia and hypotension.
• Broad ligament hematomas are
palpable as mass adjacent to
the uterus.
• Expanding hematomas require
incision and drainage.
Coagulopathy
• Continued bleeding
but no clotting.
• Bruising, petechiae,
bleeding from puncture
sites, nose, mouth, GI
tract, and vagina.
• Caused by clotting
disorders, HELLP or
DIC.
Disseminated Intravascular
Coagulation (DIC)
• Causes simultaneous uncontrolled
bleeding and clotting.
• May lead to stroke, myocardial
infarction, end-organ dysfunction,
shock, death.
• In hospital treatment includes
treating the cause and transfusion
of blood products or injection of
heparin.
DIC
Causes.
– Severe blood loss.
– Amniotic fluid embolism.
– Abruption.
– Sepsis.
– Retained fetal demise.
– Trauma.
DIC
OOH treatment.
• Rapid transport with EMS.
• Bilateral large-bore IVs of
lactated ringers or normal saline.
• Minimize skin punctures.
• Draw blood.
• Oxygen.
• Left lateral flat positioning.
• Frequent reassessment of vital
signs, fetal heart tones, uterine
tone, bleeding.
Invasive Placenta
• Placenta invades beyond normal
cleavage plane.
– Into uterine wall (placenta
accreta).
– Into uterine muscle (placenta
increta).
– Through uterine wall (placenta
percreta).
• Life-threatening hemorrhage occurs
when provider attempts manual
removal of placenta.
Uterine Inversion
• Uterus turns inside out and protrudes.
– Through cervical os (incomplete).
– Into vagina (complete).
– Beyond the vulva (prolapsed).
• Very rare, more common in
multiparous women.
• May result from attendant pulling on
cord.
• Presents with shock and lifethreatening hemorrhage.
Uterine Inversion
– Replace uterus without
removing the placenta
with palm pressing from
inside the uterus.
– After replacement, give
uterotonic medications.
– Surgical replacement or
hysterectomy may be
necessary.
Late Postpartum Hemorrhage
• Excessive bleeding 24
hr to 12 weeks
postpartum.
• From subinvolution,
retained products,
infection, diffuse atony.
• Not usually as heavy
as that immediate
PPH.
Postpartum Hemorrhage
Priorities
• Get help.
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ABCs.
Fundal massage.
Trendelenberg positioning.
Uterotonics.
Treat for shock.
Remove retained products.
Repair traumatic bleeding.
Oxygen 10 liters by nonrebreather mask.
Large bore IVs of rapidly infusing
crystalloid.
Baseline labs—CBC, PT, PTT
fibrinogen.
Insert Foley.
Rapid transport if unstable.
PPH – “DAMIT”
to dam the flow of blood
• D Deliver placenta.
• A Aggressively massage uterus.
Assess for retained products,
coagulopathy and trauma.
• M Meds — oxytocin,
methylergonovine or prostaglandins.
• I IV, shock positioning, oxygen,
bimanual compression.
• T Transport rapidly.
First Thought,
Worst Thought:
• What is the most likely cause
of postpartum hemorrhage?
– Atony.
• What is the worst it could be?
– Uncontrollable hemorrhage,
DIC, shock.
The advice and strategies presented herein
are not intended for use by
nonprofessionals, may not be appropriate
for every situation, and should not be used
outside the applicable protocol or scope of
practice. Neither the author nor the
publisher shall have any liability to any
person or entity with respect to any loss or
damage caused or alleged to be caused
directly or indirectly by the information
presented.

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