Antepartum and Postpatum Haemorrhage Quiz (April 2010)

1)Name three possible causes for vaginal bleeding during pregnancy.
ANSWER Post-coital, assault, low lying placenta, miscarriage, placental abruption, cervical erosion, polyps, cervical ecropion, vasa praevia, infection, uterine rupture, etc etc

2) At 33/40, a woman is admitted to the unit with PV bleeding and abdominal pain. Which examination would you NOT perform before checking her ultrasound scan report and why?
ANSWER Digital vaginal examination as bleeding during pregnancy could be due to a low lying placenta at the os. The scan report will confirm the position of the placenta. If there is no way of determining the position of the placenta, a speculum examination should be performed to visualise the OS and assess bleeding.

3) In the situation in question 2, why would abdominal pain with bleeding concern the midwife on duty?
ANSWER Bleeding with pain could indicate the woman is suffering from a placental abruption.

4) What is the official estimated blood loss volume for a PPH?
=/> 500ml. Some units are only counting >1000ml, or a smaller blood loss may be described as a PPH if the woman is symptomatic

5) Name the three most common causes for postpartum haemorrhage.
ANSWERS - atonic uterus (about 80%), retained products (ie placenta), vulval/vaginal lacerations

6) Oxytocic drugs aid separation of the placenta and contraction of the uterus in addition to the use during treatment of a PPH. “Synt” is the name often used to describe the both of the two drugs. What are the full names of the drugs and what is the difference between the two?
ANSWER Syntocinon and Syntometrine. Syntometrine contains both Syntocinon AND Ergometrine.

7) Why is the placenta examined after delivery?
ANSWER To ensure that all the placenta has been delivered as even tiny pieces of membranes remaining in the uterus/OS could cause the woman to continue to bleed to expel the remaining product, or could cause infection.

8) You are caring for a woman on the labour ward. The placenta has been delivered and the woman is still “trickling”. What is the reason for “rubbing up a contraction”?
ANSWER To mimic the contractions which help the uterus contract after the delivery of the placenta to close the placental site where the bleeding is usually coming from.

9) In the hospital, faced with a major PPH, the first thing you would do is call for help. Name 4 of the people you would want to be involved.
ANSWERS - senior midwife, obstetrician, consultant obstetrician, haematologist, scribe, anaesthetist, etc. Paediatrician not required unless there is a problem with the baby

10) Midwives are often taught to bear in mind that the four causes of PPH are 'tone, tissue, trauma and thrombin'. What is thrombin, and why might it be relevant?
ANSWER - Thrombin is involved in clotting/coagulation of blood, if there is no other discernable cause for the PPH, it is possible that the woman has an underlying clotting problem, and as her blood isn't clotting, the bleeding can't stop.

BONUS QUESTION Vasa Praevia occurs where the blood vessels normally enclosed in the umbilical cord run through the membranes close to or across the internal cervical os. Why is it that rupture of a vasa praevia is likely to cause the loss of the baby?
ANSWER - the blood vessels carry fetal blood, and fetal blood volume is small (about 500ml or so), so a relatively small pv blood loss, if coming from a ruptured vasa praevia, can cause rapid and severe fetal compromise or death