1. MANAGEMENT OF
POST-PARTUM HEMORRHAGE
GC DI RENZO, MD, PHD, FRCOG, FACOG
PERUGIA, ITALY

2. Why focus on preventing
post-partum hemorrhage?
 Haemorrhage is the largest direct cause of
maternal death
 PPH is mostly unpredictable
 Most PPH is caused by uterine atony
 Evidence-based, feasible, low-cost
interventions exist
 Active management at the third stage of
labour can prevent 60% of PPH

3. Difficulties associated with comparing
post-partum hemorrhage studies
 Method to determine blood loss
– Visual underestimation 70–80%
 Conduct during third stage of labour
 Confounding factors in epidemiological
studies
 58% of trials do not report their definition
of PPH

4. Maternal Health:
some ( underestimated) statistics
 180–200 millions pregnancies per year
 75 millions unwanted pregnancies
 50 millions induced abortions
 20 millions unsafe abortions
 358,000 maternal deaths (1000 per day)
 1 death every 1,5 min
 20 maternal morbidities per minute
 10-15 millions disabilities each year
WHO, 2010

5. Maternal Death Clock
 380 women become pregnant
Every Minute...  190 women face unplanned or
unwanted pregnancy
 110 women experience a
pregnancy related complication
 40 women have an unsafe
abortion
 1 woman dies from a pregnancy-
related complication
 20 women suffer of a disabilty
related to childbirth
WHO, 2010

6. About two thirds of maternal deaths are due to
 Anemia-Hemorrhage
 Obstructed delivery They can be
 Eclampsia treated by a
health
 Sepsis professional
 Unsafe abortion

7. Causes of maternal
mortality

9. Maternal mortality from post-
partum hemorrhage in the UK
6
Maternal mortality rate/million
5
4
3
2
1
0
85–87 88–90 91–93 94–96 97–99 00–02
Year
Hall M. 2004; Why mothers die (2000–2002) CEMACH.
88% received substandard care

10. Sub-standard care
 Organisational problems
– Inappropriate booking
– Inadequate blood transfusion
– Intensive care facilities
 Poor quality of resuscitation
– Inadequate transfusion
– Blood products
 Equipment failure
– Malfunctioning of specimen transport system
 Failure to recognise or treat antenatal medical
conditions
– Inherited bleeding disorders
 Failure of senior staff to attend
Hall M. 2004; Why mothers die (2000–2002) CEMACH.
 Concerns about the quality of surgical treatment

11. As with many problems,
there seems to be two
different kinds of
emergencies...
...depending on whether the
patient is in a developed or
undeveloped country

12. Developed countries
 Sequence:  Diagnosis PPH
 Protocol-
management
 Treatment
 Success (>98%)

13. Undeveloped countries
• Sequence: • Diagnosis PPH (?)
• Emergency (?)
• Transfer (?)
• Centre (?)
• Treatment (?)
• Success (<60%)

14. Post-partum hemorrhage
Equal opportunity Not equal
occurrence opportunity killer
 2/3 no risk factors  Poor
 Malnourished
 Unhealthy

15. What is post-partum
hemorrhage?
 Excess blood loss
after the birth of a
baby
 PPH >500 ml (3.5–
30%)
 Severe PPH >1000 ml
(1.5–5.0%)
Immediate PPH:

– Onset within 24 h of birth
These definitions are notPPH late:
 accepted by all!!
– Onset after 24 h of birth

17. One of the main problem……
UNDERESTIMATION OF BLOOD
LOSS

18. Methods used to diagnose
post-partum hemorrhage
 Clinical methods
– Physiological response to blood loss
 Quantitative methods
– Visual assessment
– Direct collection of blood into bedpan or
plastic bags
– Gravimetric method
– Changes in hematocrit and haemoglobin
– Others
 Plasma volume
 Tagged erythrocytes

19. Estimated blood loss
30
Visual
Measured
Estimated blood loss (%)
25
20
15
10
5
0
>500 ml >1,000 ml
Prasertcharoensuk et al. IJGO 2000

20. Calibrated bag
(Brass-V)

21. Risk factors
1. placenta previa with or without previous
uterine surgery.
2. previous myomectomy.
3. previous cesarean delivery.
4. Asherman's syndrome. (treated surgically)
5. submucous leiomyomata.
6. maternal age of 36 years and older.

22. Risk factors
(multivariable analysis)
 Retained placenta, OR=3.5
 Failure to progress to second stage, OR=3.4
 Placenta accreta, OR=3.3
 Lacerations, OR=2.4
 Instrumental delivery, OR=2.3
 Newborn large for gestational age, OR=1.9
 Hypertensive disorders, OR=1.7
 Induction of labour, OR=1.4
 Augmentation of labour with oxytocin, OR=1.4
Sheiner E, et al. J Matern Fetal Neonatal Med 2005.

23. Obstetrics & Gynecology 1985;66:89-92
Placenta Previa/Accreta and Prior Cesarean Section
STEVEN L. CLARK Et al
The risk of placenta previa was 0.26% with an
unscarred uterus and increased almost linearly with
the number of prior cesarean sections to 10% in
patients with four or more.
With a placenta previa and one previous cesarean
section, the risk of placenta accreta was 24%; this
risk continued to increase to 67% (two of three) with
a placenta previa and four or more cesarean
sections.

24. MANAGEMENT
Ch. B- Lynch
1° ed 2006
2° ed 2012

25. ( FIGO 2009 – Cape Town)

27. COMPREHENSIVE
Medical
Mechanical
Surgical

29. Joint statement management of the third stage
of labour to prevent post-partum hemorrhage
 Active management of the third stage of labour should be offered to
women since it reduces the incidence of post-partum haemorrhage
due to uterine atony
– Consists of interventions designed to facilitate the delivery of the
placenta by increasing uterine contractions and to prevent PPH
by averting uterine atony. The usual components include:
 Administration of uterotonic agents
 Controlled cord traction
 Uterine massage after delivery of the placenta, as
appropriate
 Every attendant at birth needs to have the knowledge, skills and
critical judgment needed to carry out active management of the third
stage of labour and access to needed supplies and equipment

30. Maternal outcomes of
active management trials
Active management
30 Physiological management
Patients (%)
20
10
0
Transfusion Prolonged Therapeutic Low Retained
third stage uterotonic haemoglobin placenta
drugs
McCormick et al, IJGO 2002

31. POSTPARTUM HEMORRHAGE
need of “ action” in the “golden hour”
in order to increase the probability of patient survival:
The mnemonic HAEMOSTASIS can assist in remembering
the sequence of events to confront

32. HAEMOSTASIS
H: Get HELP

33. HAEMOSTASIS
A: evaluate the vital parameters of the patient and the amount of blood
loss

34. HAEMOSTASIS
E: identify the cause (ethiology) and the appropriate
treatment (4T)
Tone
Tissue
Trauma
Trombin

35. Causes of post-partum
hemorrhage (4T)
TONE (70%)
TRAUMA CAUSE TISSUE
(19%) (10%)
THROMBIN (1%)
Anderson et al. Am Fam Physician 2007.

36. RISK FACTORS
Etiology Process Clinical Risk Factors
Tone Overdistended Uterus Polyhydramnios, Multiple Gestation
Macrosomia
Uterine Muscle Fatigue Rapid Labor, Prolonged Labor
High Parity
Intra Amniotic Infection Fever, Prolonged ROM
Functional/Anatomic Distortion of the Fibroid Uterus
Uterus Placenta Previa
Uterine Anomalies
Tissue Retained Products Incomplete Placenta at Delivery
Abnormal Placenta Previous Uterine Scar
High Parity
Retained Blood Clots Atonic Uterus
Trauma Lacerations Precipitous or Operative Delivery
Extensions at C/S Malposition, Deep Engagement
Uterine Rupture Previous Uterine Surgery
Uterine Inversion High Parity, Fundal Placenta
Thrombin Pre-existing Coagulopaties, Liver Disease
Acquired in Pregnancy ITP, DIC
Therapeutic Anti-coag History of DVT or PE

37. HAEMOSTASIS
O: proceed with oxytocin infusion, prostaglandins
( via rectal, intramuscolar, IV, intramyometrial)
First line
Second line
Third line
(off label)

39. Drugs to prevent and treat uterine atony
•Prophylactic syntometrine versus oxytocin
•Prophylactic use of oxytocin
•Carbetocin
•Injectable prostaglandins
•Misoprostol

40. Ancient Oxytocics
• Egyptian Papyrus Ebers, 1500 BC
contract uterus: speed birth, stem haemorrhage
hemp in honey
celery in milk
juniper berries
fly excrement (in many ancient pharmacopoeias)
• Dioscorides: cyclamen, 100 AD
• Ergot (Claviceps purpurea), 1582 AD
40

41. 1953: Synthesis of Oxytocin
 Vincent du Vigneaud
– American biochemist
– discovery, isolation, and synthesis
together with ADH/vasopressin
• Nobel prize in chemistry 1955
sulphur compounds of high importance
first synthesis of a polypeptide hormone
The Nobel Foundation 1955
http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.gif
T Reinheimer, 2009 41

42. Oxytocin Today
– oxytocin (sometimes combined with ergometrin)
• Labour induction/augmentation
• Prophylaxis and Treatment of Postpartum haemorrhage
retained placenta: umbilical vein injection
milk ejection/lactation: oxytocin nasal spray
Martindale 2008
http://www.appdrugs.com/ProdJPGs/OxytocinLg.jpg
T Reinheimer, 2009 42

43. Oxytocin Agonists
 Carbetocin (DURATOCIN, PABAL)
– long-acting synthetic analogue
– indication: prevention of uterine atony
– veterinary medicine
• Non-peptide agonists
patented for erectile dysfunction
WAY-262464: patented for anxiety, schizophrenia
Pritt et al. 2004, Manning et al. 2008
http://www.bcnpeptides.com/images/products/carbetocina.jpg
WO/2003/000692, US/20070117794
T Reinheimer, 2009 43

44. Mean arterial pressure (MAP)
changes with oxytocin
• 30 women with elective
Mean change of MAP (mmHg)
caesarean section
• 5 u of oxytocin either
as a bolus injection or
an infusion over 5 min
• Heart rate and intra-
arterial blood pressure
recorded every 5 s
Study period (s)
Thomas JS, et al. Br J Anaesth 2007

45. Carbetocin – Pharmacodynamics
Oxytocin Carbetocin

46. N=240
Study design: Prospective double-blind randomized controlled study
Drugs: Carbetocin 100 µg i.m. vs. syntometrine (5 IU of oxytocin and
0.5 mg of ergometrine) i.m.
Primary outcome: postpartum hemorrhage requiring additional uterotonic
therapy
Secondary outcome: incidences of postpartum hemorrhage (>500 ml) and severe
postpartum hemorrhage (>1,000 ml) as well as adverse effects profile

47. Authors Conclusion:
A single dose of intramuscular carbetocin
100µg may be more effective as
compared to a single intramuscular dose
of syntometrine (5 IU of oxytocin and 0.5
mg of ergometrine) in reducing postpartum
blood loss
 Lower incidence of adverse effects.

48. N=377
Study design: double-blind randomised single centre study
Drugs: carbetocin 100 µg or oxytocin 5 IU, both i.v.
Primary outcome: Need of additional pharmacological oxytocic interventions.
Secondary outcomes: Estimated blood loss, difference in preoperative and
postoperative haemoglobin, incidence of blood transfusion and adverse effects

49. Authors conclusion:
Carbetocin reduces the use of
additional oxytocics following
caesarean section when compared with
the licensed dose of oxytocin (5 IU)

50. Carbetocin versus oxytocin
• REVIEW: Oxytocin agonists for preventing PPH
• COMPARISON: 01 Carbetocin versus oxytocin
• OUTCOME: 02 Use of additional uterotonic therapy
Carbetocin Oxytocin RR (Fixed) Weight RR (Fixed)
Study n/N n/N 95% CI (%) 95% CI
01 Caesarean delivery
Boucher 1998 0/29 3/28 100 0.14 (0.01, 2.56)
Dansereau 1999 15/317 32/318 900 0.47 (0.26, 0.85)
Subtotal (95% CI) 346 346 100.0 0.44 (0.25,
0.78)
Total events: 15 (carbetocin), 35 (oxytocin)
Test for heterogeneity chi-square=0.66; df=1; p=0.42; I 2=0.0%
Test for overall effect z=2.81; p=0.005
02 Vaginal delivery
Boucher 2004 12/83 12/77 100.0 0.93 (0.44, 1.94)
Subtotal (95% CI) 83 77 100.0 0.93 (0.44,
1.94)
Total events: 12 (carbetocin), 12 (oxytocin)
Su LL, et for Cochrane Database Syst Rev. 2007
Test al. heterogeneity not applicable 0.001 0.1 1 10 100 1000
Favours carbetocin Favours oxytocin
Jul Test for overall effect z=0.20; p=0.8
18;(3):CD005457

52. Conclusions
Prevention of PPH
Vaginal birth: active management, Oxytocin (3-5 IU), no
prostaglandins, no ergometrin
Caesarean section: Carbetocin (Pabal®), Oxytocin 5IU 2-3min –
no bolus, no PGs, no ergometrin
Therapy of PPH
OT (10-40 IU/liter), ergometrin (0.2mg every 2-3 hours)
PGE2/PGF2alpha (0.25 mg i.m. every 15-90 min)
Misoprostol 800-1000mcg rectally (off label)
Carbetocin (off label)

53. HAEMOSTASIS
S: transfer the patient to the operating room
( exclude trauma or retained products, proceed with bimanual
compression)

54. HAEMOSTASIS
T: “Balloon Tamponade”;

55. HAEMOSTASIS
T: “Balloon Tamponade”;
Uterine packing
(2009)

56. Traditional
method
Bakri balloon

57. TAMPONADE WITH
BAKRI BALLOON
– Simple and efficient (87-95 % success rate)
– Applicable after cesarean and vaginal births
– Used as method of prevention in “cesareans at high
hemorrhagic risk” (placental pathologies, uterine
over-distension, preeclampsia, precedent
hysterotomy, coagulopathy, etc) and in the case of
contraindications for prostaglandins (asthma,
glaucoma, important hepatic and renal dysfunction)
– Easy to insert and remove
– Continuous monitoring of blood loss

58. BAKRI BALLOON
 The Bakri is a balloon in silicon, latex-free, which is filled
with physiological solution (500 cc max) and is able to
create a real intrinsic compression on the myometrial
walls: the filling volume can be varied in relation to the
dimension of the uterus and the contractile response
 Additionally to the ease of insertion it has the
possibility to monitor the amount of blood loss
thanks to the drainage holes located in the distal part of
the catheter, which is attached to a sac in order to
collect the fluids. This access is used also to perform
washings of the uterine cavit y.
 Associate adequate antibiotic coverage
 Removal of the balloon within 24 hrs administering
uterotonics/uterokinetics before deflating

59. Bakri balloon

60. The intrauterine balloon Ultrasound
Bladder
Bakri
balloon
Bakri
balloon
myoma
Catetere
vescicale
BAKRI
BALLOON

61. HAEMOSTASIS
A: apply “sutures”

62. HAEMOSTASIS
A: apply “ compression sutures”

63. B-Lynch suture

64. HAEMOSTASIS
A: apply “compressive sutures”
Hayman uterine compressive sutures Cho multiple quadrate sutures
Does not necessitate to open
the uterine cavity

65. HAEMOSTASIS
A: perform “ sutures”
Suture of Hayman

66. HAEMOSTASIS
S: Systematic pelvic devascularization
Rescue Surgery: Ligation uterine artery and ovarian artery
Triple ligation of Tsiruinikov :
ligation of the uterine arteries, round ligament and the uterine-ovarian.

68. Vascular ligation
– Uterine
– Ovarian
– Int iliac

69. Vascular ligation

70. HAEMOSTASIS Rescue Surgery
Ligation hypogastric artery
Underneath the superior gluteal
artery

71. Hypogastric artery ligation
success 84%
Hansch E, etal. AJOG 1999

72. HAEMOSTASIS
I: Interventional radiologist –”Uterine Artery Embolization”
(Limiting factors: hemodinamically stable cases - presence of angiographist - transport to
radiology)
Fragments of gelfoam are
injected (gelatin sponge
resorbable in 10-30 days)

73. HAEMOSTASIS
I: Interventional radiologist –”Uterine Artery Embolisation”

74. HAEMOSTASIS
S : Subtotal or total abdominal hysterectomy
Rescue Surgery :
total hysterectomy / subtotal
1.55 % births
0.24% and 0.90% of all cesarean sections
ISTAT 2006 between 1480 and 1800 hysterectomies/year
associated with cesarean section

75. The ideal treatment should be:
intuitive and easy to apply
secure and effective in the
“prevention” and the arrest of
hemorrhages
has an immediate result
avoids hysterectomy

76. Our Philosophy…

77. Team work
EFFICACY & EFFICIENCY

78. •TEAM- Obstetricians, Anesthetists,
Blood bank, Interventional Radiologists
Max therapeutic efforts
within 2-3 hrs
Contemporary
involvement of all
professional figures
Liberal use of all
therapeutic agents

79. Follow in a stepwise way the guidelines

80. BASICS
INFORMED CONSENT
1. INTERVENTIONAL RADIOLOGISTS IN THE
THEATRE
2. CLAMPING UTERINE VESSELS BEFORE
PLACENTAL DELIVERY
3. ASSOCIATION OF COMPRESSIVE SUTURES
AND BAKRI BALLOON

81. B-Lynch + Bakri Balloon
“ SANDWICH EFFECT“

82. B-Lynch + Bakri Balloon
IT LOOKS LIKE THE LUGGAGES
OF IMMIGRANTS…..
NO RISK OF ISCHEMIA

83. Prevention of Postpartum Hemorrhage
( cases with elevated hemorrhagic risk: i.e., placenta previa post-C.S.)
PRELIMINARY PROPHYLACTIC
STEP 1 CATHETERIZATION OF THE DESCENDING
AORTA
EXTRACTION OF THE FETUS BY C.S. AND
STEP 2
PLACENTAL DELIVERY
MULTIPLE QUADRATE ENDOUTERINE
STEP 3 HEMOSTATIC SUTURES
PREPARATION OF B-LYNCH COMPRESSIVE
STEP 4 SUTURES
APPLICATION OF HYDROSTATIC BALLOON
STEP 5
(BAKRI-BALLOON)
REPOSITIONING OF UTERUS –UTERINE SUTURES-
HYDROSTATIC BALLOON INFLATION-B-LYNCH
STEP 6
LIGATURE
IF THESE MANEUVRES FAIL
DEVASCOLARIZATING LIGATURE /SELECTIVE EMBOLIZATION
/HYSTERECTOMY

84. transomeral/transfemoral pre-carefour
STEP 1
Angiography

85. STEP 2 DELIVERY OF THE FETUS
ADMINISTRATION OF CARBETOCIN

86. STEP 2
CLAMPING UTERINE VESSELS

87. Prevention of postpartum hemorrhage
( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )
Assistance Plan
STEP 2 Squared hemostatic endouterine sutures
Rationale: at the level of the inferior uterine segment reduced muscular
component ; incomplete mechanical hemostasis after placental delivery;
conspicuous hemorrhage
multiple quadrate sutures in
the IUS of 2-3 cm,
transdecidual. (Dexon n.1-
2,needle with large curvature )
Retraction of the muscular
fibers with clamping and
e occlusion of the vasculature
m
s
Affront
i

88. STEP 3 Squared hemostatic endouterine sutures

89. Prevention of postpartum hemorrhage
( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )
Assistance Plan
STEP 3 B-Lynch compressive sutures
The ligature of the sutures follows after STEP 4

90. PREPARATION OF
STEP 4 B-LYNCH SUTURE

91. STEP 4

92. Prevention of postpartum hemorrhage
STEP 4 Application of hydrostatic balloon (Bakri balloon)
Uterine closure
Hydrostatic balloon inflation
B-Lynch suture ligature

93. BAKRI-BALLOON POSITIONING
STEP 5

94. MILD INFLATION OF THE BALLOON
STEP 5

95. REPOSITIONING THE UTERUS;
STEP 6 FULL INFLATION OF BALLOON;
B-LINCH SUTURE APPLIED

96. postpartum
hemorrhage
( Ex adiuvantibus )

97. postpartum hemorrhage
( Ex adiuvantibus )
Separatore cellulare a flusso continuo
Unità di gestione della temperatura corporea

98. postpartum hemorrhage
ADULT INTENSIVE CARE UNIT POSTPARTUM

99. ONGOING
END POINT :
SURGICAL CONSERVATIVE TREATMENT
REACHED 95% ( 78 OUT OF 82 )
• 4 HYSTERECTOMIES

100. DIFFICULT CASES……. US SCAN

101. DIFFICULT CASES…. RMN

102. DIFFICULT CASES ….
US SCAN CHECK AFTER 30 DAYS

103. ( 02.09.2011)
DIFFICULT CASES...

104. DIFFICULT CASES...... ( 02.09.2011)

105. ( 02.09.2011)
DIFFICULT CASES...

106. DIFFICULT CASES...

107. CESAREAN
HYSTERECTOMY

108. CESAREAN
HYSTERECTOMY

109. CESAREAN
HYSTERECTOMY

110. CESAREAN
HYSTERECTOMY

111. Considerations
All pregnancies are at risk of hemorrage in the post partum
even if at the moment of birth there were no risk factors.
Because our goal is to improve maternal health and prevent the
possibility of death during the pregnancy or birth it is
fundamental
to possess, other than a
solid preparation,
a trustworthy and well trained team and
the necessary instruments.
( Bakri balloon;Cell sorter with continuous flow; FloSeal)

113. New conservative approach in the management of PPH
G. Clerici, G. Epicoco, E. Bottaccioli, S. Arena, I. Giardina, G. C. Di Renzo, G. Affonti
University Hospital of Perugia, Perugia, Italy
CONSERVATIVE MANAGEMENT PROTOCOL
METHODS
A retrospective study of 49 patients (since October STEP 1 –Preliminary prophylactic
2007) with placenta previa/accreta who underwent a catheterization of the descending aorta
conservative management protocol (see table).
STEP 2 –Extraction of the fetus by C.S. and
RESULTS placental delivery E
M
S
Conservative management of PPH was successfully Affronti
achieved in 48 patients (98%). In only one case it was STEP 3 –Multiple quadrate endouterine
necessary to perform post-partum hysterectomy for haemostatic sutures
massive bleeding due to severe placental accretism.
In another case it was necessary selective STEP 4-Preparation of B-Lynch compressive
embolization of the right uterine artery due to the sutures
presence of hematoma in the right part of the lower
uterine segment and in the right paracolpus. STEP 5 –Application of hydrostatic balloon
The mean estimated blood loss was 1620 ml (range (Bakri balloon)
1100-2340 ml). The mean hospital stay was 5.5 days
(range 4-10 days). 22 patients (45%) underwent STEP 6 –Repositioning of uterus - uterine
INTRODUCTION sutures - hydrostatic balloon inflation – B-
intraoperative and postoperative blood transfusions
Postpartum hemorrhage (PPH) is the leading Lynch ligature
and the mean transfused volume was 700 ml. 18
cause of maternal death worldwide. Most
patients (37%) were admitted for 24-48 h to intensive
deaths occur within the first 4 hours after If the maneuvers fail the next step is
care unit for intensive monitoring. 30% of patients
delivery, often as a consequence of placental devascolarizating ligature/selective
experienced moderate fever in the first 24-48 h and
delivery. Treatment option for PPH include embolization of the uterine arteries.
they were treated with antibiotics.
conservative management (uteritonic drugs, If all procedures fail, proceed with
selective devascularization by ligation or hysterectomy.
embolization of the uterine artery, external
CONCLUSIONS
compression with uterine sutures and • Monitoring of maternal hematologic
All pregnancies are at risk of PPH. Its management is
intrauterine packing). Failure of these parameters 24 hrs before C.S. and 2 h after
dictated by several considerations including
options necessitates hysterectomy. the procedure, than every 2-4 h for the
hemodynamic status and desire to preserve fertility.
The objective of the study is to report our following 24 hrs in relation to clinical
Conservative interventions should represent
experience with a conservative management conditions.
mandatory step for treatment of PPH in high risk
protocol to treat PPH in high risk patients • Blood transfusion if the hemoglobin level
patients with placenta previa/accreta. The results of
diagnosed with placenta previa/accreta. decreases more than 7 g/dl and the
this conservative protocol are encouraging .
hematocrit value is less than 21% ;
• The Bakri balloon is removed 24 h after
delivery.

114. CONCLUSIONS

115. FACTS:
All pregnancies are at risk of
PPH even if no predisposing
factors are present
Luis G. Keith 2007

116. BOTTOM LINE
Averting maternal death is
based on having a prepared
mind, a prepared team and
a full range of possible
therapies
Luis G. Keith, 2007

117. Postpartum Hemorrhage
Recommendations:
•Every department needs to have a protocol for
management of O.E., with periodic re-evaluation (Life
Support training)
•Cases at risk of E.O. need to give birth in a II-III level
structure
•Uncontrollable hemorrhages may necessitate
hysterectomy: an expert surgeon needs to be avaliable
quickly 24 hrs a day
•Activate the multidisciplinary team early in the
management of a case at risk
•Institutional guidelines for the treatment of hemorrhages
with periodic simulation training (skills and drills)

118. THANK YOU