1. MANAGEMENT OF POST PARTUM HAEMORRHAGE DRILL

2. Contributors Dr. Jyoti Bhaskar Dr. Jyoti Agarwal Dr. Sharda Patra
Dr. Sharda Jain

3. MDG 5
MMR IN – 178 ( from 212)
MMR – 109 by 2015

4. MATERNAL MORTALITY Our Best Estimate is A Gross Underestimate
200,000 women die from PPH each year**
35-56%

5. It is estimated that, if untreated, Death occurs on average in:
How much time do we have ?
It is estimated that, if untreated,
Death occurs on average in:
2 hours from Postpartum Hemorrhage
12 hours from Antepartum Hemorrhage
2 days from Obstructed Labor
6 days from Infection

6. WHY DRILLS IN OBSTETRICS ?
PPH
Death from PPH is avoidable
Are Mostly Unexpected –
Immediate and Adequate
action needed

7. High Risk Situations
Medico- Legal Consequences

8. Guidelines of RCOG Green top No.52 May 2009
COMMUNICATE.
RESUSCITATE.
MONITOR / INVESTIGATE.
STOP THE BLEEDING.

9. CALL FOR HELP

10. CALL

11. RESUSCITATE A
AIRWAY
BREATHNG
CIRCULATION

12. 14 GUAZE – 2 IN NUMBER Full blood count
Venepuncture (20 ml) for:
Crossmatch (4 units minimum)
Full blood count
Coagulation screen including fibrinogen
Renal and liver function for baseline.
START RINGER LACTATE TILL BLOOD COMES

13. Transfuse blood as soon as possible
Infuse 2 litres of warmed Crystalloid Hartmann’s solution
Colloid (1–2 litres) as rapidly as required.
RAPID WARMED infusion of fluids.

14. If crossmatched blood is still unavailable
Uncrossmatched Group Specific Blood OR
‘O RhD Negative” Blood

15. MONITORING Keep position Flat
Keep the woman warm using appropriate available measures.
Temperature every 15 mts
Continuous pulse, blood pressure recording and respiratory rate
Foley catheter to monitor urine output.
Documentation of fluid balance, blood, blood products and procedures.

16. STOP THE BLEEDING
Tone
Tissue
Trauma
Thrombin

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

18. UTEROTONICS -- OXYTOCIN
10 IU IM. Or
20–40 IU in 1 L of normal saline at 60 drops per minute.
Continue oxytocin infusion (20 IU in 1 L of IV fluid at 40 drops per minute) until hemorrhage stops
FIGO Safe Motherhood and Newborn Health (SMNH) Committee /
International Journal of Gynecology and Obstetrics 117 (2012) 108–118

19. OXYTOCIN – FIRST LINE Storage preferred storage is refrigeration
it may be stored at temperatures up to 30 °C for up to 3 months without significant loss of potency

20. ERGOMETRINE Dose: 0.2 mg im or slow iv
Repeat 0.2 mg after I/M can be repeated every 2-4 hrs
Maximum 5 doses (1 mg) in 24 hr
Storage:2–8 °C and protect from light and from freezing
Hypertension is a relative contraindication
Contraindicated with concomitant use of certain drugs used
to treat HIV

21. OR
Syntometrine (combination of oxytocin 5 units and ergometrine 0.5 mg).
1 ampoule IM (warning, IV could cause hypotension).

22. OR
Misoprostol (if oxytocin is not available or administration is not feasible).
Single dose of 800 μg sublingually (4×200-μg tablets).
Storage: aluminum blister pack, room temperature, in a closed container.

23. OR CARBOPROST Dose: 0.25 mg im. Can be repeated every 15 min.
Maximum upto 2 mg or 8 doses.

24. AORTIC COMPRESSION It is simple life saving procedure
Aortic compression may be used to stop bleeding at any stage.
Ideally, the birth attendant should accompany the woman during transfer
FIGO GUIDELINES 2012
Prevention and treatment of postpartum hemorrhage in low-resource settings☆
FIGO Safe Motherhood and Newborn Health (SMNH) Committee

25. AORTIC COMPRESSION

26. Non-Inflatable Anti-Shock Garment

27. If conservative measures fail to control haemorrhage
Initiate Surgical Haemostasis
SOONER
RATHER THAN
LATER

28. Internal Uterine Tamponade

29. CONDOM BALLON TAMPONADE

30. B-Lynch “Brace” Suture

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

32. Embolisation

33. Resort to hysterectomy
SOONER RATHER
THAN LATER
(especially in cases of placenta accreta or uterine rupture)

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

35. REMEMBER
GOLDEN HOUR OF RESUSCITATION
RULE OF 30
HAEMOSTASIS ALGORYTHM

36. HAEMOSTASIS algorithm
H- ask for help
A- assess (vitals, blood loss) & resuscitate
E -
Establish etiology(tone,tissue,trauma,thrombine)
Ecbolics (syntometrine,ergometrine)
Ensure availability of blood
M - massage the uterus
O – oxytocin infusion & prostaglandin

37. S-
Shift to operating theatre
Bimanual compression
Pneumatic anti-shock garment
T- Tissue & trauma to be excluded
A- apply compression sutures
S- systematic pelvic devascularisation
I - interventional radiology
S- subtotal/total hysterectomy

38. INNOVATIVE TECHNIQUES FOR LOW RESOURCE SETTINGS
EASY AND ACCURATE BLOOD LOSS MEASUREMENT

39. OXYTOCIN IN UNIJECT Single Prefilled Nonreusable Easy to use .
Compact size

40. Non-Inflatable Anti-Shock Garment

41. TOOL KIT FOR PPH

43. It is an Enigma It is sudden often unpredicted assessed subjectively
Can be catastrophic.
The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

44. To Conclude, Management of PPH Has Evolved From:
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness 44

45. THANK YOU
Reminds Us -- Every mother has to be Saved