PPH Drill Dr. Jyoti Bhaskar , Dr. Sharda Jain , Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar
Dr. Jyoti Agarwal
Dr. Sharda Patra
Dr. Sharda Jain
MMR – 109 by 2015
MMR IN 2010-2012 – 178 ( from 212)
Our Best Estimate is A Gross
from PPH each
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
WHY DRILLS IN OBSTETRICS ?
• Death from PPH is avoidable
• Are Mostly Unexpected –
Immediate and Adequate
High Risk Situations
Medico- Legal Consequences
Guidelines of RCOG
Green top No.52 May 2009
MONITOR / INVESTIGATE.
STOP THE BLEEDING.
14 GUAZE – 2 IN NUMBER
Venepuncture (20 ml)
• Crossmatch (4 units minimum)
• Full blood count
• Coagulation screen including
• Renal and liver function for
START RINGER LACTATE
TILL BLOOD COMES
Transfuse blood as soon as
• Infuse 2 litres of
• Colloid (1–2 litres) as
rapidly as required.
• RAPID WARMED
infusion of fluids.
If crossmatched blood is still
Uncrossmatched Group Specific Blood
‘O RhD Negative” Blood
• Keep position Flat
• Keep the woman warm using appropriate
• Temperature every 15 mts
• Continuous pulse, blood pressure recording and
• Foley catheter to monitor urine output.
Documentation of fluid balance, blood, blood products and procedures.
If uterus is relaxed :
massaging the uterus
will expel any
retained bits &
UTEROTONICS -- OXYTOCIN
10 IU IM.
• 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
FIGO Safe Motherhood and Newborn Health (SMNH) Committee /
International Journal of Gynecology and Obstetrics 117 (2012) 108–118
OXYTOCIN – FIRST LINE
• preferred storage is refrigeration
• it may be stored at temperatures up to 30 °C for
up to 3 months without significant loss of
Dose: 0.2 mg im or slow iv
Repeat 0.2 mg after I/M can be repeated every 2-4
Maximum 5 doses (1 mg) in 24 hr
Storage:2–8 °C and protect from light and from
•Hypertension is a relative contraindication
•Contraindicated with concomitant use of certain drugs used
to treat HIV
• Syntometrine (combination of oxytocin 5
units and ergometrine 0.5 mg).
1 ampoule IM (warning, IV could cause
• 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.
Dose: 0.25 mg im.
Can be repeated every 15 min.
Maximum upto 2 mg or 8 doses.
• 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
(especially in cases of placenta accreta or
Resort to hysterectomy
Documentation and Debriefing
Important to record:
• Sequence of events
• Time and sequence of administration of
pharmacological agents, fluids, blood
• The time of surgical intervention
• The condition of mother throughout .
• GOLDEN HOUR OF RESUSCITATION
• RULE OF 30
• HAEMOSTASIS ALGORYTHM
• H- ask for help
• A- assess (vitals, blood loss) & resuscitate
• E -
3.Ensure availability of blood
• M - massage the uterus
• O – oxytocin infusion & prostaglandin
Shift to operating theatre
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
INNOVATIVE TECHNIQUES FOR
LOW RESOURCE SETTINGS
• EASY AND ACCURATE BLOOD LOSS
OXYTOCIN IN UNIJECT
• Easy to use
• Compact size
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.
To Conclude, Management of PPH
Has Evolved From: