3. PPHPPH
Single most important cause of maternalSingle most important cause of maternal
mortality worldwide.mortality worldwide.
Accounts for 34% of maternal deaths inAccounts for 34% of maternal deaths in
developing countries.developing countries.
4. DefinitionDefinition
Any blood loss than has potential toAny blood loss than has potential to
produce or produces hemodynamicproduce or produces hemodynamic
instabilityinstability
5. DefinitionDefinition
Blood loss > 500 ml after deliveryBlood loss > 500 ml after delivery
> 1000 ml after LSCS> 1000 ml after LSCS
Minor : 500-1000 mlMinor : 500-1000 ml
Moderate : 1000-2000 mlModerate : 1000-2000 ml
Severe : > 2000 mlSevere : > 2000 ml
7. PREDICTION AND PREVENTIONPREDICTION AND PREVENTION
Identify pt. at riskIdentify pt. at risk
-- Pl previa/accretaPl previa/accreta
- Anticoagulation RxAnticoagulation Rx
- CoagulopathyCoagulopathy
- Overdistended uterusOverdistended uterus
- Grand multiparityGrand multiparity
- Abn labor patternAbn labor pattern
- ChorioamnionitisChorioamnionitis
- Large myomasLarge myomas
- Previous history ofPrevious history of
PPHPPH
8. PREVENTIONPREVENTION
Regular ANCRegular ANC
Correction of anaemiaCorrection of anaemia
Identification of high risk casesIdentification of high risk cases
Delivery in hospital with facility for EmergencyDelivery in hospital with facility for Emergency
Obstetric Care.Obstetric Care.
Otherwise transport to the nearest such hospital atOtherwise transport to the nearest such hospital at
the earliest.the earliest.
Keep speedy transport availableKeep speedy transport available
ACTIVE MANAGEMENT OF 3ACTIVE MANAGEMENT OF 3RDRD
STAGE OF LABOURSTAGE OF LABOUR
44thth
Stage of labour - Observation, OxytocinStage of labour - Observation, Oxytocin
9. ACTIVE MANAGEMENT OF 3ACTIVE MANAGEMENT OF 3RDRD
STAGE OF LABOUR (WHO-1989)STAGE OF LABOUR (WHO-1989)
Oxytocics - Routine use in third stageOxytocics - Routine use in third stage →→ bloodblood
lossloss ↓↓ by 30-40% and risk of PPH by 60%by 30-40% and risk of PPH by 60%
5 or 10 U Oxytocin IM5 or 10 U Oxytocin IM
Syntometrine 1 Amp IMSyntometrine 1 Amp IM
Ergometrine 1 Amp IV/IMErgometrine 1 Amp IV/IM
-- Misoprost in home birth settings-- Misoprost in home birth settings
Early cord clampingEarly cord clamping
Controlled cord tractionControlled cord traction
Inspection of placenta & lower genital tractInspection of placenta & lower genital tract
CS settings -5 U of oxytocin IV bolus , CarbetocinCS settings -5 U of oxytocin IV bolus , Carbetocin
11. It is an EnigmaIt is an Enigma
IIt 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.
12. ““The golden hour” of resuscitationThe golden hour” of resuscitation
““Rule of 30”Rule of 30”
if SBP falls by 30mmHg,if SBP falls by 30mmHg,
HR rises by 30 beats/min,HR rises by 30 beats/min,
RR ↑to 30breaths/min,RR ↑to 30breaths/min,
HCT drop by 30%,HCT drop by 30%,
urine output <30ml/hrurine output <30ml/hr
lost at least 30% of her blood volumelost at least 30% of her blood volume
13. Guidelines of RCOGGuidelines of RCOG
Green top No.52 May 2009Green top No.52 May 2009
COMMUNICATE.COMMUNICATE.
RESUSCITATE.RESUSCITATE.
MONITOR / INVESTIGATE.MONITOR / INVESTIGATE.
STOP THE BLEEDINGSTOP THE BLEEDING..
15. COMMUNICATECOMMUNICATE
CallCall experienced midwifeexperienced midwife
CallCall OObstetric registrar & alert consultantbstetric registrar & alert consultant
CallCall anaesthetic registrar , alert consultantanaesthetic registrar , alert consultant
AlertAlert haematologisthaematologist
AlertAlert Blood Transfusion ServiceBlood Transfusion Service
CallCall porters for delivery of specimens / bloodporters for delivery of specimens / blood
Alert one member of the team to record events,
fluids, drugs and vital signs
16. RESUSCITATERESUSCITATE
MINOR PPH (blood loss 500–1000 ml, no
clinical shock):
Intravenous access (14-G cannula x 1).
Commence crystalloid infusion.
Consider venepuncture (20 ml) for:
Group and screen
Full blood count
Coagulation screen including fibrinogen
Pulse and blood pressure recording every 15
minutes.
17. Full protocol for MAJOR PPH (blood loss >
1000 ml and continuing to bleed OR clinical
shock):
Assess
Airway.
Breathing.
Circulation
Oxygen by mask at 10–15 litres/minute.
Intravenous access (14-gauge cannula x 2, orange
cannulae).
Position flat.
Keep the woman warm using appropriate available
measures.
18. Transfuse blood as soon as possible.
Until blood is available, Infuse up to 3.5
litres of warmed Crystalloid Hartmann’s
solution (2 litres) and or Colloid (1–2 litres)
as rapidly as required.
The best equipment available should be
used to achieve RAPID WARMED
infusion of fluids.
19. Fluid Therapy and Blood ProductsFluid Therapy and Blood Products
Crystalloid Up to 2 litres Hartmann’s solution
Colloid Up to 1–2 litres colloid until blood
arrives
Blood If crossmatched blood is still
unavailable, give uncrossmatched
group-specific blood OR give ‘O RhD
negative’ blood
Fresh Frozen Plasma 4 units for every 6 units of red cells
or PT/ APTT > 1.5 x normal
(12–15 ml/kg or total 1 litre)
Platelets concentrates if PLT count < 50 x 109
Cryoprecipitate If fibrinogen < 1 g/l
Upto 1 litre of FFP and 10 units of Cryoprecipitate can be
given in case of relentless bleeding.
20. Main Therapeutic GoalsMain Therapeutic Goals
Main therapeutic goals of management of
massive blood loss is to maintain:
haemoglobin > 8g/dl
platelet count > 75 x 109/l
prothrombin < 1.5 x mean control
activated prothrombin times < 1.5 x mean
control
fibrinogen > 1.0 g/l.
21. Recombinant Factor VIIRecombinant Factor VII
In the face of life-threatening PPH, and in
consultation with a haematologist, rFVIIa may
be used as an adjuvant
Dose is 90 micrograms/kg, repeated in the
absence of clinical response within 15–30
minutes.
Fibrinogen should be above 1g/l and platelets
greater than 20 x 109/l before rFVIIa is given
22. MONITOR / INVESTIGATEMONITOR / INVESTIGATE
Consider venepuncture (20 ml) for:
Crossmatch (4 units minimum)
full blood count
coagulation screen including fibrinogen
renal and liver function for baseline.
Monitor temperature every 15 minutes.
Continuous pulse, blood pressure recording
and respiratory rate (using oximeter,
electrocardiogram and automated blood pressure
recording).
Foley catheter to monitor urine output.
23. Consider arterial line monitoring (once
appropriately experienced staff available for
insertion).
Consider transfer to ITU once the bleeding is
controlled or monitoring at high dependency unit
on delivery suite, if appropriate.
Recording of parameters on a flow chart
such as the modified obstetric early warning
system charts.
Documentation of fluid balance, blood,
blood products and procedures.
24. The Four “T”The Four “T”
ToneTone
TissueTissue
TraumaTrauma
ThrombinThrombin
25. BimanualBimanual
CompressionCompression
If uterus is relaxed :If uterus is relaxed :
massaging the uterusmassaging the uterus
will expel anywill expel any
retained bits &retained bits &
stimulate uterinestimulate uterine
contractionscontractions
26. Administer Uterotonic DrugsAdminister Uterotonic Drugs
FIRST LINEFIRST LINE
Oxytocin:Oxytocin:
Start with 5 units slow iv or im.Start with 5 units slow iv or im.
Infusion of 20 units in 1 L@ 60 dr/min.Infusion of 20 units in 1 L@ 60 dr/min.
Continue same dose @ 40 dr/min until bleedingContinue same dose @ 40 dr/min until bleeding
stops.stops.
Maximum upto 3 L.Maximum upto 3 L.
27. SECOND LINESECOND LINE
Ergometrine/ methyl ergometrine:Ergometrine/ methyl ergometrine:
Dose: 0.2 mg im or slow ivDose: 0.2 mg im or slow iv
Repeat 0.2 mg after 15 min.Repeat 0.2 mg after 15 min.
Maximum 5 doses (1 mg)Maximum 5 doses (1 mg)
SyntometrineSyntometrine imim
28. THIRD LINETHIRD LINE
PGF 2PGF 2αα::
Dose: 0.25 mg im.Dose: 0.25 mg im.
Can be repeated every 15 min.Can be repeated every 15 min.
Maximum upto 2 mg or 8 doses.Maximum upto 2 mg or 8 doses.
Misoprostol:Misoprostol:
200-800 µg sublingually/per rectal200-800 µg sublingually/per rectal
Do not exceed 1000 µgDo not exceed 1000 µg
WHO GUIDELINES FOR MANAGEMENT OF PPH 2009WHO GUIDELINES FOR MANAGEMENT OF PPH 2009
29. If conservative measures fail to controlIf conservative measures fail to control
haemorrhage, initiate surgical haemostasishaemorrhage, initiate surgical haemostasis
SOONER RATHER THAN LATERSOONER RATHER THAN LATER
Balloon tamponade
Haemostatic brace suturing (such as
using procedures described by B-Lynch
or modified compression sutures)
Bilateral ligation of uterine arteries
Bilateral ligation of internal iliac
(hypogastric) arteries
Selective arterial embolisation.
31. Procedure of condom BalloonProcedure of condom Balloon
insertioninsertion
InitialInitial
AssemblyAssembly
Condoms-2Condoms-2
Foley’s catheter-Foley’s catheter-
no.16no.16
Saline with iv setSaline with iv set
SpeculumSpeculum
Sponge holdingSponge holding
forceps
32. ProcedureProcedure
Lithotomy positionLithotomy position
Indwelling Foley’sIndwelling Foley’s
catheter.catheter.
Explore uterus, cervixExplore uterus, cervix
and vagina.and vagina.
Inflate balloon withInflate balloon with
100-300 ml warm100-300 ml warm
0.9% Sodium0.9% Sodium
chloride until bleedingchloride until bleeding
is controlled (is controlled (PositivePositive
36. Uterine Artery EmbolizationUterine Artery Embolization
Possible only ifPossible only if
internal arteryinternal artery
ligation has not beenligation has not been
done and facility fordone and facility for
interventionalinterventional
radiology availableradiology available
37. Resort to hysterectomyResort to hysterectomy
SOONER RATHERSOONER RATHER
THAN LATER (especiallyTHAN LATER (especially
in cases of placenta accretain cases of placenta accreta
or uterine rupture)or uterine rupture)
38. Documentation and DebriefingDocumentation and Debriefing
Important to record:Important to record:
Sequence of eventsSequence of events
Time and sequence of administration ofTime and sequence of administration of
pharmacological agents, fluids, bloodpharmacological agents, fluids, blood
productsproducts
The time of surgical interventionThe time of surgical intervention
The condition of mother throughout .The condition of mother throughout .
39. HAEMOSTASIS algorithmHAEMOSTASIS algorithm
H- ask for helpH- ask for help
A- assess (vitals, blood loss) & resuscitateA- assess (vitals, blood loss) & resuscitate
E -E -
1.1. EstablishEstablish
etiology(tone,tissue,trauma,thrombine)etiology(tone,tissue,trauma,thrombine)
2.2. Ecbolics (syntometrine,ergometrine)Ecbolics (syntometrine,ergometrine)
3.3. Ensure availability of bloodEnsure availability of blood
M - massage the uterusM - massage the uterus
O – oxytocin infusion & prostaglandinO – oxytocin infusion & prostaglandin
40. § S-S-
Ø shift to operating theatreshift to operating theatre
Ø Bimanual compressionBimanual compression
Ø Pneumatic anti-shock garmentPneumatic anti-shock garment
T- Tissue & trauma to be excludedT- Tissue & trauma to be excluded
A- apply compression suturesA- apply compression sutures
S- systematic pelvic devascularisationS- systematic pelvic devascularisation
I - interventional radiologyI - interventional radiology
S- subtotal/total hysterectomyS- subtotal/total hysterectomy
41. ConclusionConclusion
We NeedWe Need
Intelligent anticipationIntelligent anticipation
Skilled supervisionSkilled supervision
Prompt detectionPrompt detection
Effective institution of therapyEffective institution of therapy
to prevent disastrous consequences of PPHto prevent disastrous consequences of PPH..
42. To Conclude, Management of PPHTo Conclude, Management of PPH
Has Evolved From:Has Evolved From:
PanicPanic
PanicPanic
HysterectomyHysterectomy
Pitocin
Prostaglandins
Happiness
43.
44. IncidenceIncidence
PPH is one of the commonest cause of maternalPPH is one of the commonest cause of maternal
mortality & accounts for 1/4mortality & accounts for 1/4thth
of all maternal deathof all maternal death
worldwide. (WHO 2005)worldwide. (WHO 2005)
In developing countries it accounts over 1/3In developing countries it accounts over 1/3rdrd
of allof all
maternal death. (Khan KS 2006)maternal death. (Khan KS 2006)
14 million cases occur each year with a case fatality14 million cases occur each year with a case fatality
rate of 1%.(WHO 2004)rate of 1%.(WHO 2004)
In India PPH responsible forIn India PPH responsible for 15-20%15-20% 0f maternal0f maternal
death ( Mukherjee et al 2002).death ( Mukherjee et al 2002).
45. Post Partum haemorrhagePost Partum haemorrhage
. . . the most common and severe type of obstetric
haemmorrhage, is an enigma even to the
present day obstetrician as it is sudden,
often unpredicted, assessed subjectively
and can be catastrophic. The clinical
picture changes so rapidly that unless
timely action is taken maternal death
occurs within a short period.
46. ““women are not dying because of awomen are not dying because of a
disease we cannot treat. They aredisease we cannot treat. They are
dying because societies have yet todying because societies have yet to
make decision that their lives aremake decision that their lives are
worth saving”worth saving”
Mamoud Fathalla,Mamoud Fathalla,
President of FOGSI.19President of FOGSI.199797
47. Case ScenarioCase Scenario
Doctor is delivering the placenta – afterDoctor is delivering the placenta – after
delivery of placenta she has a sudden gushdelivery of placenta she has a sudden gush
of bleeding.of bleeding.
48. ABCABC
VitalsVitals
Call for helpCall for help
CannulaCannula
InvestigationInvestigation
FluidsFluids
Cause for bleedingCause for bleeding
Treatment accordinglyTreatment accordingly
49. Case Scenario 2Case Scenario 2
No doctor available –No doctor available –
Baby has been delivered.Baby has been delivered.
Pt is known to be anaemic .Pt is known to be anaemic .
How will you manage the third stage so as toHow will you manage the third stage so as to
prevent PPHprevent PPH
