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Pph drill
Pph drill
Pph drill
Pph drill
Pph drill
Pph drill
Pph drill
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Pph drill
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Pph drill

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  • 1. Dr. Monika Madaan Specialist Dept. Of Obstetrics & Gynaecology ESI Hospital Manesar
  • 2. PPH Single most important cause of maternal mortality worldwide. Accounts for 34% of maternal deaths in developing countries.
  • 3. Definition Any blood loss than has potential to produce or produces hemodynamic instability
  • 4. Definition Blood loss > 500 ml after delivery Primary : Loss within 1st 24 hours after delivery Secondary : 24 hours till 12 weeks postnatally Minor : 500-1000 ml Moderate : 1000-2000 ml Severe : > 2000 ml
  • 5. PREDICTION AND PREVENTION - Pl previa/accreta - Anticoagulation Rx - Coagulopathy - Overdistended uterus Identify pt. at risk - Grand multiparity - Abn labor pattern - Chorioamnionitis - Large myomas - Previous history of PPH
  • 6. PREDICTION AND PREVENTION Active Management Of Third Stage Of Labor (AMTSL): Should be offered routinely and includes: 1.Administration of uterotonics soon after birth. 2.Delayed cord clamping. 3.Delivery of placenta by controlled cord traction followed by uterine massage.
  • 7. PPH Drill Clear and logical sequence of steps essential in the management of PPH.
  • 8. CALL FOR HELP
  • 9. Team Effort •Skilled Obstetric Team •Trained Anaesthesiologist •Clinical hematologist •Supporting staff
  • 10. Resuscitation Assess A : Airway B : Breathing C : Circulation  Secure 2 wide bore i.v. lines:- 14-16 gauge  Draw blood for grouping & cross matching, CBC, LFT/KFT, SE & Coagulogram.
  • 11. Position flat Keep the patient warm Administer oxygen by mask ( @ 10-15 litres/ min) Catheterize the patient for emptying bladder & monitoring output
  • 12. Fluid Replacement RAPID WARMED infusion of fluids Crystalloids : Fluids of choice until compatible blood is arranged 1 ml of blood loss= 3 ml of crystalloids Total volume of 3.5 litres of clear fluids (upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.
  • 13. If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given
  • 14. FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal (ie 12-15 ml/kg or total of 1 litres.) Platelet Concentrate: if Platelet count< 50,000/ microlitre. Cryoprecipitate: if fibrinogen < 1 g/ l.
  • 15. Continuous vital monitoring. Monitor adequacy of replacement with urine output (0.5 ml/kg/hr) and CVP (4-8 cm water) Main therapeutic goals are to maintain: Haemoglobin > 8gm/dl Platelet count > 75 × 109 / l Prothrombin < 1.5 × mean control APTT < 1.5 × mean control Fibrinogen > 1 gm/ l
  • 16. Establish Etiology Simultaneously 4 T’s Tone (abnormalities of uterine contraction) : 70 – 80% Trauma (of the genital tract) : 20 % Tissue (retained products of conception) : 10 % Thrombin (abnormalities of coagulation) : 1 %
  • 17. Contd…
  • 18. Bimanual Compression If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions
  • 19. Administer Uterotonic Drugs FIRST LINE Oxytocin: Start with 5 units slow iv or im. Infusion of 20 units in 1 L@ 60 dr/min. Continue same dose @ 40 dr/min until bleeding stops. Maximum upto 3 L. SECOND LINE Ergometrine/ methyl ergometrine: Dose: 0.2 mg im or slow iv Repeat 0.2 mg after 15 min. Maximum 5 doses (1 mg) Syntometrine im
  • 20. THIRD LINE PGF 2α: Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. Misoprostol: 200-800 µg sublingually. Do not exceed 800 µg WHO GUIDELINES FOR MANAGEMENT OF PPH 2009
  • 21. Uterine Tamponade • Bakri balloon • Sengstaken Blakemore oesophageal catheter • Condom catheter • Urological Rusch balloon Success depends upon Positive Tamponade test
  • 22. insertion Initial Assembly  Condoms-2  Foley’s catheter-no.16  Saline with iv set  Speculum  Sponge holding forceps
  • 23. Procedure Lithotomy position Indwelling Foley’s catheter. Explore uterus, cervix and vagina. Inflate balloon with 100300 ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).
  • 24. Compression sutures B Lynch Suture •Fundal compression suture •Apposes anterior & posterior wall
  • 25. Contd… Parallel Vertical compression sutures for placenta praevia
  • 26. Stepwise Uterine Devascularization •Uterine arteries •Tubal branch of ovarian artery •Internal iliac artery
  • 27. Uterine Artery Embolization Possible only if internal artery ligation has not been done and facility for interventional radiology available
  • 28. Hysterectomy Resort to hysterectomy “SOONER RATHER THAN LATER” High maternal morbidity Timing and adequate replacement is of utmost importance
  • 29. Documentation and Debriefing Important to record: Sequence of events Time and sequence of admn of pharmacological agents, fluids, blood products The time of surgical intervention The condition of mother throughout .
  • 30. Newer Developments Tranexamic acid : 1 gm i.v slow. Can be repeated after 30 min if bleeding continues./ Recombinant activated factor VII (Novoseven): 90 µg/ kg . May be repeated within 15-30 minutes. No clear consensus on efficacy. Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.
  • 31. HAEMOSTASIS ALGORITHM H – Ask for help A – Assess and resuscitate E – Establish etiology M – Massage the uterus O – Oxytocic administration S – Shift to OT T – Tissue n trauma to be excluded and proceed to tamponade A – Apply compression sutures S – Systematic pelvic devascularisation I – Interventional radiology S – Subtotal or total hysterectomy
  • 32. To Conclude, Management of PPH Has Evolved From: Panic Panic Hysterectomy  Pitocin  Prostaglandins  Happiness
  • 33. & ADDRESS 35 , Defence Enclave, Opp. Preet Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092 CONTACT US 011-22414049, 42401339 WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com

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