PPH Drill Dr. Jyoti Bhaskar , Dr. Sharda Jain , Dr. Jyoti Agarwal

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PPH Drill Dr. Jyoti Bhaskar , Dr. Sharda Jain , Dr. Jyoti Agarwal

  1. 1. MANAGEMENT OF POST PARTUM HAEMORRHAGE DRILL
  2. 2. Contributors Dr. Jyoti Bhaskar Dr. Jyoti Agarwal Dr. Sharda Patra Dr. Sharda Jain
  3. 3. MDG 5 MMR – 109 by 2015 MMR IN 2010-2012 – 178 ( from 212)
  4. 4. MATERNAL MORTALITY Our Best Estimate is A Gross Underestimate 35-56% 200,000 women die from PPH each year**
  5. 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. 6. WHY DRILLS IN OBSTETRICS ? PPH • Death from PPH is avoidable • Are Mostly Unexpected – Immediate and Adequate action needed
  7. 7. High Risk Situations Medico- Legal Consequences
  8. 8. Guidelines of RCOG Green top No.52 May 2009 COMMUNICATE. RESUSCITATE.  MONITOR / INVESTIGATE. STOP THE BLEEDING.
  9. 9. CALL FOR HELP
  10. 10. CALL
  11. 11. RESUSCITATE A AIRWAY BREATHNG CIRCULATION
  12. 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. 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. 14. If crossmatched blood is still unavailable Uncrossmatched Group Specific Blood OR ‘O RhD Negative” Blood
  15. 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. 16. STOP THE BLEEDING Tone Tissue Trauma Thrombin
  17. 17. Bimanual Compression If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions
  18. 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. 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. 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. 21. OR • Syntometrine (combination of oxytocin 5 units and ergometrine 0.5 mg). 1 ampoule IM (warning, IV could cause hypotension).
  22. 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. 23. OR CARBOPROST Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses.
  24. 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. 25. AORTIC COMPRESSION
  26. 26. Non-Inflatable Anti-Shock Garment
  27. 27. If conservative measures fail to control haemorrhage Initiate Surgical Haemostasis SOONER RATHER THAN LATER
  28. 28. Internal Uterine Tamponade
  29. 29. CONDOM BALLON TAMPONADE
  30. 30. B-Lynch “Brace” Suture
  31. 31. Stepwise Uterine Devascularization •Uterine arteries •Tubal branch of ovarian artery •Internal iliac artery
  32. 32. Embolisation
  33. 33. SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture) Resort to hysterectomy
  34. 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. 35. REMEMBER • GOLDEN HOUR OF RESUSCITATION • RULE OF 30 • HAEMOSTASIS ALGORYTHM
  36. 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. 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. 38. INNOVATIVE TECHNIQUES FOR LOW RESOURCE SETTINGS • EASY AND ACCURATE BLOOD LOSS MEASUREMENT
  39. 39. OXYTOCIN IN UNIJECT • Single • Prefilled • Nonreusable • Easy to use . • Compact size
  40. 40. Non-Inflatable Anti-Shock Garment
  41. 41. TOOL KIT FOR PPH
  42. 42. 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.
  43. 43. To Conclude, Management of PPH Has Evolved From: • Panic • Panic • Hysterectomy Pitocin Prostaglandins Happiness
  44. 44. Reminds Us -- Every mother has to be Saved

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