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postpartum haemorrhage recent advances

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  • 1. Prevention of Postpartum Hemorrhage Dr Shashwat Jani
  • 2. ACCIDENTS AND HAEMORRHAGE
  • 3.
    • What really kills a women ?
  • 4. PPH
    • Three delays
      • Delay in diagnosis
      • Delay in transfer
      • Delay treatment / management
  • 5. PPH
    • Three factors
      • Amount of blood loss
      • Rate of blood loss
      • Health status of woman
  • 6. PPH
    • Time interval from onset of PPH to death is 2 hours .
    • By the time clinical signs appear lost 25% of her blood volume
  • 7. BUT
    • THESE
    • CAN
    • BE
    • PREVENTED.
  • 8.
    • HOW ?
  • 9. PREVENTION
    • Regular ANC
    • Correction of anaemia
    • Identification of high risk cases
    • Delivery in hospital with facility for Emergency Obstetric Care.
    • Otherwise transport to the nearest such hospital at the earliest.
      • Keep speedy transport available
    • Local / Regional anaesthesia
    • ACTIVE MANAGEMENT OF 3 RD STAGE OF LABOUR
    • 4 th Stage of labour - Observation, Oxytocin
  • 10. Prevention of PPH in labour room
    • Anticipate PPH in every woman in labor
    • Keep emergency tray
  • 11. ANTENATAL RISK FACTORS
    • Two-thirds of women have no identifiable risk factors
    • Pre-eclampsia
    • Mediolateral episiotomy
    • Previous PPH
    • Multiple gestation
    • Previous caesarean
    • Obesity
  • 12. INTRAPARTUM RISKS
    • Prolonged 2 nd stage
    • Prolonged 3 rd stage > 30 min
    • Mediolateral episiotomy
    • Arrest of descent
    • General anaesthesia
    • Laceration
    • Augmented labour
    • Forceps delivery
  • 13. PPH
    • What must be available immediately in every place of delivery to deal such complication ?
  • 14.
    • For handling emergencies one must have a crash kit with the following
    Crash Kit (Emergency Tray)- Whole team with the patients
    • Brannula (16 ,18 ,20)
    • Bulbs- grouping and
    • cross matching
    • Venesection Set
    • Syringes/ Gloves
    • Roller gauze / mops /
    • sticking plaster, scissor
    • Foley’s catheter
    • Drip sets
    • I. V. Fluids- RL, DNS
    • Hemacel,
    • Intubation materials
    • Oxytocin,Misoprostol
    • PGF2alpha,Methergin
    • Oxygen with mask
    • Hydrocortisone
    • Calcium Gluconate
    • Deriphylline
    • Atropine
    • Adrenaline
    • Dopamine, Dobutamine
  • 15.  
  • 16.
    • THE THIRD STAGE OF LABOUR IS
    • INDEED THE UNFORGIVING STAGE
    • OF LABOUR
    • AS
    • IN IT THERE LURKS MORE
    • UNHERALDED TREACHERY THAN IN
    • FIRST TWO STAGES OF LABOUR
    • COMBINED
  • 17. Mechanism of hemostasis
    • Contraction & Retraction of myometrium.‘Living Ligatures or physiological sutures of uterus‘’ (Baskett 1990)
    • Coagulation pathway.
    • Myotamponade.
  • 18.
    • Expectant or active management
    • of third stage ?
  • 19.
    • AMTSL preferred
    • -Significanty reduces PPH by 60%
    • -Significantly decrease the need for blood
    • transfusion
    • -Need for therapeutic oxytocics was reduced by
    • 80%
    • ( Conclusive evidence from 5 randomised controlled trial and
    • WHO meta-analysis)
  • 20. Components of AMTSL
    • Immediate administration of uterotonic drug
    • Delayed clamping of the cord
    • Controlled cord traction
    • Examination of the placenta
    • Palpation of the uterus to ensure contractility every 15 min. for at least 2 hrs.
  • 21. OXYTOCIN PREFERRED
    • Oxytocin alone is very effective
    • Oxytocin does not have the adverse effect profile as those associated with preparation containing ergot (Mc Donald 2002 )
    • Oxytocin is more stable when exposed to heat and light than ergot preparations ( Favored by WHO 1993 )
    • Can be used in settings where storage capabilities is an issue
  • 22.
    • When to administer a prophylactic
    • Oxytocin in AMTSL ?
  • 23.
    • In the AMTSL prophylactic oxytocin
    • administered intramuscularly after the delivery of the baby ( Bristol and Hinchingbrooke trial )
  • 24.
    • Dosage of oxytocin recommended
    • Oxytocin 10 IU administered intramuscularly or 10-20 IU in 500 ml of crystalloid IV
    • At caesarean section oxytocin 5 IU intravenously
  • 25. The incidence of Induction of Labour is on the rise . Even otherwise, most women in labour have an IV line . Why not use the convenient Oxytocin to prevent PPH?
  • 26. Methyl-ergometrine
    • Onset- 3 to 5 min- IM &
    • 1 min for IV
    • Duration- > 3hrs-IM & 45 Min- IV
    • IV / IM 0.2 mg
  • 27.
    • More side effects
      • Nausea
      • Vomiting
      • Hypertension
    • Needs refrigeration (2-8 0 c)
    • Contraindications – Hypertension, cardiac disease etc.,
  • 28. PGF 2 α ( Carboprost.)-IM only
    • Strong uterotonic
    • 125 mcg IM can be used for prevention
  • 29. PPH
  • 30.
    • More side effects
      • Shivering
      • Nausea
      • Vomiting
      • Diarrhoea
      • Abdominal cramps
    • Avoid in asthmatics ( bronchospasm )
  • 31. Misoprostol (PGE 1 analogue)
    • Oral / rectal / vaginal/Sublingual – accepted routes of administration
    • Can be kept it room temperature up to 27 0.
    • cheap and can be by an unskilled person
  • 32. Misoprostol (PGE 1 )
    • For prevention – 600 mcg orally immediately after clamping and cutting the cord has been recommended.
  • 33. How to Refer ?
    • To proper place
    • Foot end elevated
    • With I.V. drip
    • Blood samples (For grouping & crossmatching)
    • Paramedical staff with emergency drugs
    • Prior information to the place of referral blood group
    • With a note (Diagnosis & treatment given)
    • Attenders – Young adults (for blood)
  • 34. Non inflatable anti shock garment
  • 35. Thank you….

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