1. PPH – Global and The UK Perspectives S Arulkumaran Professor & Head Obstetrics and Gynaecology St George’s University of London

2. * Other direct causes include: ectopic pregnancy, embolism, anesthesia-related ** Indirect Causes include: anemia, malaria, heart disease 75% Of MM & third of NN mortality takes place during labor/ birth or within 24 Hrs.

3. PPH Global Perspectives 30-50% of maternal deaths due to PPH Inadequate Health facilities Inadequate skilled attendance Inadequate medication or surgical facilities Long delay in reaching facilities/ providing treatment Solutions Better communication and transport Health facilities (affordable/ self respect & dignity Health personal (no need for controlled traction) Medications; PG/ Misprostol, Tranexamic acid, R Factor VII a, 1;1 PCV to Plasma transfusion Simpler techniques – Balloon Tamponade/ Compression sutures/ Anti-shock Garment

4. Strategies to Prevent Maternal Mortality Basic Emergency Obstetric Functions (6) THREE INJECTIONS Post partum Hemorrhage – Oxytocics (IV/ IM/ Oral) & active management of the third stage of labor Hypertensive Disease > Eclampsia – Antihypertensive & Anticonvulsants – Mg SO4 –IV/ IM Sepsis – post abortion or labor & delivery – Antibiotics IV/IM THREE MANUAL FUNCTION Manual removal of placenta Evacuation of the uterus of retained placental tissue Vacuum Assisted Delivery in cases of second stage delay

5. Strategies to Prevent Maternal Mortality Comprehensive Em Obstetric Functions (6 + 2) Basic Emergency Obstetric Functions + Caesarean Section Blood Transfusion Four more to be added – Misoprostol, Anti Shock Garment, Tamponade balloon & Compression suture for post partum hemorrhage + latest – no need for controlled cord traction with syntocinon; need cord traction with misoprosotol??

6. Anti Shock Garment Effective Easy to use, Re-usable

7. TAMPONADE TEST Therapeutic & Prognostic For severe PPH Stomach balloon Esophageal balloon Condous G, Arulkumaran S et.al. Obstetrics & Gynecology. 2003

8. Glove catheter No need for condom Or suture material – S Africa Condom Catheter –Bangaladesh, Sri Lanka, India - 85% success rate

9. COMPRESSION SUTURES Quick, safe and effective B-Lynch B-Lynch Horizontal full thickness sutures Horizontal full thickness sutures Vertical full thickness sutures Vertical full thickness sutures Square sutures Square sutures Combination of sutures Combination of sutures

10. B- LYNCH COMPRESSION SUTURES

11. SIMPLE VERTICAL COMPRESSION SUTURES Cornu Fallopian tube Ovary Hayman R, Arulkumaran S, Steer P Obstetrics & Gynecology. 2002

12. Conservative Surgical Treatment for PPH Method No of Cases No of Cases Success rates Success rates B-Lynch + other Compression sutures 9490.4% Arterial embolization 21891% Arterial ligation 26483.7% Uterine balloon tamponade 13583.7% Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007

13. UK – Direct deaths due to PPH Years Pl Abr Pl Pr PPH GT tr Total Rate/10 5 ‘85-’87 4 0 6 6 16 0.71 ‘88-’90 6 5 11 3 25 1.06 ‘91-’93 3 4 8 4 19 0.82 ‘94-’96 4 3 5 5 17 0.77 ‘97-’99 3 3 1 2 9 0.42 ‘’00-’02 3 4 10 1 18 0.90 ‘03-’05 2 3 9 3 17 0.80 ‘06-’08 2 2 5 0 9 0.39 Karoshi et.al. 2012

14. Karoshi et.al. 2012

16. TOP TEN RECOMMENDATIONS

17. PPH in the UK (UKOSS) Major obstetric haemorrhage 3.7/1000 maternities (370/ 100,000) Uterine atony was major cause of haemorrhage Feb 2005 - Feb 2006 – Postpartum Hysterectomy to control haemorrhage -40.6 for 100,000 maternities (CI – 36.3 – 45.4) Severe PPH – specific 24.4/100,000 – uterine compression suture, pelvic vessel ligation, embolisation. Factor VII a (CI - 21.7-27.3) The effect of balloon tamponade was not evaluated?

18. CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS TOO LITTLE – TOO LATE TOO LITTLE – TOO LATE Too Little (IV fluids, oxytocics, BLOOD, Clotting factors) Too Late (PG, resuscitation - blood replacement, decision for surgery + to get senior surgeon & anaesthetist involved ) Placenta Accreta – special problem

19. Response of the Professional Bodies RCOG/ NPSA/ RCA/ RCR RCOG Green top guidelines 1. Postpartum haemorrhage; Prevention and Management 2. Blood transfusion in Obstetrics 3. Placenta Praevia, Placenta Praevia accreta, vasa praveia; Diagnosis and management RCOG Good Practise guidelines 1. The role of Interventional radiology in Obstetrics 2. Responsibility of consultant on call 3. The maternity dashboard NPSA – Care bundle for the management of placenta Accreta www.rc.og.org.ukwww.rc.og.org.uk Google – Greentop guidelines

20. GREEN TOP GUIDELINES ‘THE PREVENTION & MANAGEMENT OF PPH’

22. Algorithm for management of Atonic PPH ‘HAEMOSTASIS’ Algorithm for management of Atonic PPH ‘HAEMOSTASIS’ H- Ask for Help H- Ask for Help A- Assess vital parameters & blood loss and Resuscitate – (Rule of 30) A- Assess vital parameters & blood loss and Resuscitate – (Rule of 30) E-Establish etiology + Ecbolics (syntometrine, ergometrine, bolus syntocinon) + Ensure availability of blood. E-Establish etiology + Ecbolics (syntometrine, ergometrine, bolus syntocinon) + Ensure availability of blood. M-Massage Uterus – bimanual compression M-Massage Uterus – bimanual compression O-Oxytocin infusion / prostaglandins - intravenous / per rectal / intramuscular / intra- myometrial/ Tranexamic acid O-Oxytocin infusion / prostaglandins - intravenous / per rectal / intramuscular / intra- myometrial/ Tranexamic acid

23. Algorithm for management of Atonic PPH ‘HAEMOSTASIS’ S- Shift to OT - Shock Garment (anti) - Aortic compression/ Bimanual compression S- Shift to OT - Shock Garment (anti) - Aortic compression/ Bimanual compression T- (4 T’s) Tissue/ Trauma/Tone/Thrombin > Tamponade (before coagulopathy)– Balloon / packing T- (4 T’s) Tissue/ Trauma/Tone/Thrombin > Tamponade (before coagulopathy)– Balloon / packing A- Apply compression sutures – B- Lynch / modified/ +/- Balloon A- Apply compression sutures – B- Lynch / modified/ +/- Balloon S- Systematic Pelvic devascularisation – Uterine / Ovarian / Quadruple / internal iliac S- Systematic Pelvic devascularisation – Uterine / Ovarian / Quadruple / internal iliac I- Interventional Radiology – If appropriate, Uterine artery embolisation I- Interventional Radiology – If appropriate, Uterine artery embolisation S- Subtotal / Total abdominal hysterectomy S- Subtotal / Total abdominal hysterectomy

24. Conservative Surgical Tr. for PPH Method No of Cases No of Cases Success rates Success rates B-Lynch + other Compression sutures 9490.4% Arterial embolization 21891% Arterial ligation 26483.7% Uterine balloon tamponade 13583.7% Doumouchtsis S, Papageorghiou A, Arulkumaran S. Obstet Gyne Survey 2007

26. Massive PPH - Surgical Techniques Near Miss Enquiries - Scotland Use of Balloon techniques – 6 in ’03 > 42 in ’06 Use of Balloon techniques – 6 in ’03 > 42 in ’06 Haemostatic compression sutures – 10 in ’03 >24 in ’06. Haemostatic compression sutures – 10 in ’03 >24 in ’06. Over 4 years; 106 balloon techniques - 95% success rate; 76 brace sutures – 83% success rate Over 4 years; 106 balloon techniques - 95% success rate; 76 brace sutures – 83% success rate Peripartum hysterectomy – 15% in 2003 > 8% in 2006 Peripartum hysterectomy – 15% in 2003 > 8% in 2006 Avoidable delay in diagnosis & management –8% Avoidable delay in diagnosis & management –8% Failure to follow protocol/plan – 6% Failure to follow protocol/plan – 6%

27. From April 2010 – CNST audit requirement - Pilot CQC – building risk profile of Hospitals

28. Responsibility of Consultant on Call (RCOG advice – 2009) Labour ward duties (safer childbirth) Must attend – Major Post Partum Haemorrhage – Eclamptic fit – Collapsed patient – Major placenta praevia – Return to theatre -Laparotomy – When trainee asks for it Be present (depending upon trainee’s experience) – Trial of instrumental delivery – Twins/preterm labour C/S / vaginal Breech delivery – C/S at full dilatation/ for Transverse lie/ BMI >40

29. Maternity Dashboard Royal College of Obstetricians and Gynaecologists The Maternity Dashboard – Tool to monitor implementation of principles of clinical governance ‘on the ground ’. A powerful, visible way of continually monitoring and assessing how a unit is doing. Enables teams to respond in a timely and appropriate manner to ensure a safe and responsive high-quality service. Helps to develop an ethos of total quality improvement. www.rcog.org.uk/womens-health/clinical- guidance/maternity-dashboard-clinical- performance-and-governance-score-card

30. Performance & Governance Score Card ‘ Maternity Dashboard ’ Designed by Prof. Arulkumaran & Team – Northwick Park Recommended by CMO’s Report Looks at Activity, Staffing, Clinical Risk indicators, User feedback (e.g. complaints)

31. Maternity Dashboard - Ensures high quality safe care.- Tool for Commissioners, Providers, Consumers and Regulators Massive PPH, blood transfusion, hysterectomies, admission to ICU KNOWLEDGE TRANSFER N MEOWS CHART

32. More Medical and Simpler Surgical Techniques should help to reduce morbidity & mortality THANK YOU