13: Emergencies after delivery

CHAPTER 13
Emergencies after delivery


13.1 Primary postpartum haemorrhage


Definition


Primary PPH is defined as a blood loss of 500 ml or more within 24 hours of delivery and affects 3–5% of all deliveries. Massive PPH is clinically more important and may be life‐threatening. A reasonable definition of massive PPH is ‘loss of 50% of the blood volume within 3 hours of delivery’. Bleeding that is not so acute but continues at a rate of 150 ml/h or more, may also lead to unexpected maternal collapse. Bleeding that leads to haemodynamic instability would be another reasonable definition.


Between 2013 and 2015 there were 21 deaths that were reported as being related to haemorrhage, and this group continues to be the second leading cause of death occurring within 42 days of the end of pregnancy (MBRRACE‐UK, 2017).


Risk factors



  • Previous antepartum haemorrhage (APH) or PPH
  • Long labour
  • Anything that enlarges the uterus – multiple pregnancy, excess liquor (polyhydramnios), large baby
  • Maternal age more than 40 years
  • Obesity
  • Multiparity (especially with five deliveries or more)
  • Chorioamnionitis (intrauterine infection)
  • Uterine fibroids (whether known or not)
  • Partial separation of the placenta


The ‘four Ts’ is a simple tool to remind you of the common causes of primary PPH (RCOG, 2009a):



  • Tone
  • Trauma
  • Tissue
  • Thrombin

The most common cause (70%) is poor uterine tone. Trauma accounts for 20% and may involve any part of the genital tract and includes tears of the vulva, vagina or cervix, as well as uterine rupture, which should be considered in cases of labour with a uterine scar (most commonly a previous caesarean section). Tissue cases (10%) could involve retention of part of, or the whole, placenta. Thrombin refers to the development of disseminated intravascular coagulation (DIC), where blood clotting mechanisms are deranged and signs include bleeding from venous puncture sites; blood that is passed does not form clots.


Diagnosis


Blood loss is notoriously difficult to estimate accurately and there is a tendency to underestimate (for estimating blood loss, see Figure 6.2). Maternal physiological changes include a significant increase in circulating volume, which means that during pregnancy (and immediately after delivery), women do not exhibit overt warning signs of imminent collapse. In pregnancy, pulse and blood pressure are usually maintained in the normal range until blood loss exceeds 1000 ml. Tachycardia, tachypnoea and a slight recordable fall in systolic BP occur with blood loss of 1000–1500 ml. A systolic BP below 80 mmHg, associated with worsening tachycardia, tachypnoea and altered mental state, usually indicates a PPH in excess of 1500 ml.


If bleeding is more than expected it is recommended that early venous access is obtained with large‐bore cannulae.


Although bleeding is obvious in most cases of major PPH, occasionally hypovolaemic shock can occur without overt bleeding. In these cases, consider haemorrhage that is ‘concealed’ – places where significant amounts of blood can accumulate include the paravaginal tissues (a haematoma of 2 litres or more may accumulate in the tissue space) and intra‐abdominally (if there has been a uterine rupture).


Pre‐hospital management



  1. Fully assess ABCs – manage shock as described in Chapter 7.
  2. Estimate the amount of visible bleeding (then ‘double the estimate’).
  3. Consider the causes of primary PPH (the ‘four Ts’) – the commonest reason is uterine atony.
  4. Feel for the uterine fundus – it normally feels ‘hard and firm’ and just reaches the umbilicus.
  5. If the uterus feels ‘soft and doughy’, use the hand that is holding the fundus to ‘rub up’ a contraction (Box 13.1 and Figure 13.1).
  6. Give a bolus dose of an oxytocic drug if bleeding continues (e.g. syntometrine IM or misoprostol PR).
  7. With the mother’s permission, check the vulval and perineal areas for obvious tears that might be bleeding. Local compression should be applied to control bleeding.
  8. If possible, consider catheterisation to empty the bladder as this will help the uterus contract.
  9. If the uterus is not contracting and haemorrhage is increasing, institute bimanual uterine compression (Box 13.2 and Figure 13.2). This will rarely be needed but may be a life‐saving manoeuvre.
  10. Arrange immediate transfer to a staffed obstetric unit.
  11. Provide the receiving hospital with a pre‐alert call.

Image described by caption.

Figure 13.1 ‘Rubbing up’ a uterine contraction: the left hand is cupped over the uterus and massages it with a firm, circular motion in a clockwise direction

Gloved hands with the right hand forming a fist inserted into the vagina and the left hand pressing into the abdomen behind the uterus.

Figure 13.2 Bimanual uterine compression


13.2 Secondary postpartum haemorrhage


Definition


This is bleeding that occurs between 24 hours and 6 weeks post‐delivery. It most commonly occurs between the 5th and 10th day.


Risk factors



  • Infection
  • Retention of placental tissue


Diagnosis



  • Bleeding following delivery may have temporarily ceased or reduced but then increases
  • Bleeding can be severe
  • Bleeding may be associated with cramps, generalised abdominal pain and back pain
  • There may be an associated pyrexia and general malaise
  • The blood loss may have an offensive odour


Pre‐hospital management



  1. Obtain a history of the delivery.
  2. Treat as per shock guidelines (see Chapter 7).
  3. Retain any tissue that has been passed and bring to the hospital.


13.3 Trauma to the birth canal


Definition


Perineal trauma


This can be defined as:



  • First degree, i.e. tear involving just the vaginal wall. If there is minimal bleeding, suturing is not required
  • Second degree, i.e. tear involving the perineal muscles with a corresponding tear in the vagina. Usually requires suturing, but this may be done in the woman’s home by the midwife
  • Third degree includes the anal sphincter and always requires suturing in the hospital
  • Fourth degree includes the anal mucosa and always requires suturing in the hospital
  • Other lacerations: labial tears and grazes are common; if they are not bleeding, they do not require sutures

Cervical trauma



  • The cervix may tear if the fetus passes through an incompletely dilated cervix
  • It may be associated with other tears
  • Occasionally, an obstetrician may cut the cervix in the case of head entrapment with a preterm breech delivery


Uterine trauma



  • Usually associated with previous uterine surgery such as caesarean section or myomectomy
  • This may present post‐natally with vaginal bleeding and/or shock


Haematomas


Vulval – rupture of a vulval varix (varicose vein) or associated with perineal trauma. This can occur with a normal delivery and apparently intact perineum. An obvious painful swelling will be seen on one side of the vulva. It may present with severe buttock pain.


Vaginal – blood can accumulate in the space on either side of the vagina. There may or may not be pain and bleeding. This is a large potential space where several litres of blood may accumulate. Usually, nothing is visible on inspection of the vulva and the woman will eventually present with shock.


Broad ligament – the level of shock is out of proportion to the amount of blood loss seen.

Mar 9, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on 13: Emergencies after delivery
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