This document provides guidelines for managing postpartum haemorrhage (PPH). It emphasizes the need for immediate action, as death from PPH is usually rapid without treatment. The guidelines recommend following the principles of CALL, RESUSCITATE, MONITOR/INVESTIGATE, and STOP THE BLEEDING. First-line treatment includes uterotonics like oxytocin, ergometrine, and misoprostol. Other measures discussed include bimanual compression, condom catheter tamponade, and surgical techniques if conservative options fail. Early recognition, teamwork, and following standardized protocols are essential to optimize outcomes for mothers experiencing PPH.

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 – 109 by 2015
MMR IN 2010-2012 – 178 ( from 212)

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

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

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

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 -
1.Establish
etiology(tone,tissue,trauma,thrombine)
2.Ecbolics (syntometrine,ergometrine)
3.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
• Panic
• Hysterectomy
Pitocin
Prostaglandins
Happiness

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