1. Dept. Of Obstetrics & Gynaecology
PPH Drill
Dr. Monika Madaan
Specialist
Dept. Of Obstetrics & Gynaecology
ESI Hospital Manesar

2. PPH Single most important cause of maternal mortality worldwide.
Accounts for 34% of maternal deaths in developing countries.

3. Definition
Any blood loss than has potential to produce or produces hemodynamic instability

4. Definition Blood loss > 500 ml after delivery
Primary : Loss within 1st 24 hours after delivery
Secondary : 24 hours till 12 weeks postnatally
Minor : ml
Moderate : ml
Severe : > 2000 ml

5. PREDICTION AND PREVENTION
- Pl previa/accreta
Anticoagulation Rx
Coagulopathy
Overdistended uterus
Grand multiparity
Abn labor pattern
Chorioamnionitis
Large myomas
Previous history of PPH
Identify pt. at risk

6. PREDICTION AND PREVENTION
Active Management Of Third Stage Of Labor (AMTSL): Should be offered routinely and includes:
Administration of uterotonics soon after birth.
Delayed cord clamping.
Delivery of placenta by controlled cord traction followed by uterine massage.

7. PPH Drill
Clear and logical sequence of steps essential in the management of PPH.

8. CALL FOR HELP

9. Skilled Obstetric Team Trained Anaesthesiologist Clinical hematologist
Team Effort
Skilled Obstetric Team
Trained Anaesthesiologist
Clinical hematologist
Supporting staff

10. Resuscitation Assess A : Airway B : Breathing C : Circulation
Secure 2 wide bore i.v. lines: gauge
Draw blood for grouping & cross matching, CBC, LFT/KFT, SE & Coagulogram.

11. Position flat
Keep the patient warm
Administer oxygen by mask litres/ min)
Catheterize the patient for emptying bladder & monitoring output

12. Fluid Replacement RAPID WARMED infusion of fluids
Crystalloids : Fluids of choice until compatible blood is arranged
1 ml of blood loss= 3 ml of crystalloids
Total volume of 3.5 litres of clear fluids (upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.

13. If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given

14. FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1
FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal
(ie ml/kg or total of 1 litres.)
Platelet Concentrate: if Platelet count< 50,000/ microlitre.
Cryoprecipitate: if fibrinogen < 1 g/ l.

15. Continuous vital monitoring.
Monitor adequacy of replacement with urine output (0.5 ml/kg/hr) and CVP (4-8 cm water)
Main therapeutic goals are to maintain:
Haemoglobin > 8gm/dl
Platelet count > 75 × 109 / l
Prothrombin < 1.5 × mean control
APTT < 1.5 × mean control
Fibrinogen > 1 gm/ l

16. Establish Etiology Simultaneously
4 T’s
Tone (abnormalities of uterine contraction) : 70 – 80%
Trauma (of the genital tract) : 20 %
Tissue (retained products of conception) : 10 %
Thrombin (abnormalities of coagulation) : 1 %

17. Explore cervix and vagina
Contd…
Check tone of uterus
well contracted
Suspect trauma
Explore cervix and vagina

18. Bimanual Compression
If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions

19. Administer Uterotonic Drugs
FIRST LINE
Oxytocin:
Start with 5 units slow iv or im.
Infusion of 20 units in 1 60 dr/min.
Continue same 40 dr/min until bleeding stops.
Maximum upto 3 L.
SECOND LINE
Ergometrine/ methyl ergometrine:
Dose: 0.2 mg im or slow iv
Repeat 0.2 mg after 15 min.
Maximum 5 doses (1 mg)
Syntometrine im

20. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses.
THIRD LINE
PGF 2α:
Dose: 0.25 mg im.
Can be repeated every 15 min.
Maximum upto 2 mg or 8 doses.
Misoprostol:
µg sublingually.
Do not exceed 800 µg
WHO GUIDELINES FOR MANAGEMENT OF PPH 2009

21. Uterine Tamponade Sengstaken Blakemore oesophageal catheter
Bakri balloon
Sengstaken Blakemore oesophageal catheter
Condom catheter
Urological Rusch balloon
Success depends upon Positive Tamponade test

22. Procedure of condom Balloon insertion
Initial Assembly
Condoms-2
Foley’s catheter-no.16
Saline with iv set
Speculum
Sponge holding forceps

23. Procedure Lithotomy position Indwelling Foley’s catheter.
Explore uterus, cervix and vagina.
Inflate balloon with ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).

24. Compression sutures B Lynch Suture Fundal compression suture
Apposes anterior & posterior wall

25. Contd…
Parallel Vertical compression sutures for placenta praevia

26. Stepwise Uterine Devascularization
Uterine arteries
Tubal branch of ovarian artery
Internal iliac artery

27. Uterine Artery Embolization
Possible only if internal artery ligation has not been done and facility for interventional radiology available

28. Hysterectomy Resort to hysterectomy “SOONER RATHER THAN LATER”
High maternal morbidity
Timing and adequate replacement is of utmost importance

29. Documentation and Debriefing
Important to record:
Sequence of events
Time and sequence of admn of pharmacological agents, fluids, blood products
The time of surgical intervention
The condition of mother throughout .

30. Newer Developments
Tranexamic acid : 1 gm i.v slow. Can be repeated after 30 min if bleeding continues./
Recombinant activated factor VII (Novoseven): 90 µg/ kg . May be repeated within minutes. No clear consensus on efficacy.
Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.

31. HAEMOSTASIS ALGORITHM
H – Ask for help A – Assess and resuscitate E – Establish etiology M – Massage the uterus O – Oxytocic administration S – Shift to OT T – Tissue n trauma to be excluded and proceed to tamponade A – Apply compression sutures S – Systematic pelvic devascularisation I – Interventional radiology S – Subtotal or total hysterectomy

32. To Conclude, Management of PPH Has Evolved From:
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness

33. THANK YOU