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PPH & ShockDr Sunita Singal,SJH ND
Objectives To detect PPH & assess degree of shock Identify types of PPH To develop skills and best practices formanagem...
Haemorrhage is common Most common cause of maternal deathworldwide Probably accounts for more than 30-38% ofall maternal...
Haemorrhage is often not recognized Blood loss is underestimated because inpregnancy signs of hypovolaemia do not showunt...
PREVENTION STRATEGYFOR PPH
AMTSL: ACTIVEMANAGEMENT OF THIRDSTAGE OF LABOUR
The classical expectant management• Wait for the natural forces of labor to bringabout 3rd stage contraction and placental...
WHAT IS AMTSL :Active managementof 3rd stage• Oxytocic administration immediately afterdelivery of the baby so that the ut...
Benefits of AMTSL• Uterine atony accounts for 70-90% of all PPH cases• AMTSL reduces:Incidence of PPH by 60%Quantity of ...
PPHaemorrhage - causes4Ts: Tone: uterine atony, Tissue: retained placenta or retained products, Tears: cervical or peri...
Symptoms& signsAssociatedfindingsProbablediagnosisImmediate PPHUterus soft &not contractedBleeding maybe continuousor Inte...
Diagnosing the cause of PPHPortion of placentamissing ormembranes tornUterus relaxedPPHRetainedplacentalfragmentsUterine f...
Shock due to Haemorrhage Shock is a life threatening condition thatrequires immediate, intensive treatment The presence ...
Signs Present? When signs are there they are SIGNIFICANT Have a high suspicion and ACT QUICKLY!
Shock due to Haemorrhage –Signs Pale Confused Increased HR Reduced BP (late sign) Reduced urine output Obvious or hi...
Signs of shock Brain -unconscious, anxious, agitated andconfused, drowsy Skin - sweaty or cold and clammy Breathing - r...
Haemorrhage - management Follow the protocol ABCs C - replace the volume- stop the bleeding
Haemorrhage ABCs Circulation IV access by 2 large bore cannulae Send off blood samples Give iv fluids16G – GREY: 1 li...
Shock- immediate actionCirculation Get iv access and send blood samples If pulse>100 / minute or BP< 90 mm Hg or heavy v...
How much fluid, How fast?• Volume of 3x the estimated loss as crystalloids(up to 4L) then as colloids• Give blood early – ...
Be aware of blood lost!Signs Blood lost ActionMild increase inpulse-700 mls Give iv fluidsIncrease in pulseand respiratory...
Shock- immediate action Ascertain the cause of haemorrhage Cover her and keep her warm Keep a careful record of input a...
Diagnosing the cause of PPHThe most important step in making a diagnosisof the cause of PPH is to keep a hand on thelower ...
PPH – How to manageStepwise approach in case of uterineatony
Uterine atony Empty bladder Give Oxytocics Check for placenta completeness genital tract injury Rub uterus Bimanual...
Management (Contd.) Massage uterus to expel clots and feel tosee that it is contracted—recheckintermittently Give oxytoc...
Oxytocic DrugsOxytocin Ergometrine/ 15-methylprostaglandin F2Dose and Route IV: Infuse 20units in 1 L at60 drop/min.IM: 10...
Bimanual Compression of Uterus Wearing sterile gloves,insert hand into vagina;form fist Place fist into anteriorfornix a...
Bimanual Compression of Uterus(contd.) With other hand, press deeply into abdomenbehind uterus, applying pressure against...
Compression of Abdominal Aorta Apply downward pressure withclosed fist over abdominal aortadirectly through abdominal wal...
Compression of Abdominal Aorta(Contd.)• Maintain compressionuntil bleeding iscontrolled
Uterine Tamponade (1)
Uterine Tamponade (2)Up to 500mls or until the uterus is contracted
RETAINED PLACENTA: MRP•IV oxytocin, oxygen, Empty bladder, CCT•If CCT not successful, on PV it can be felt incervix, grasp...
Traumatic PPH Episiotomy Perineal tears and lacerations Vaginal tears Cervical tears Uterine rupture Broad ligament ...
Follow-up care in atonic PPH• Monitor the vital signs( pulse, BP, RR)• every 10 min. for the first 30 mins,• every 15 mins...
 Not a common condition Pulling on the umbilical cord in theabsence of a uterine contraction in aneffort to deliver the ...
Manual replacement of uterus Give the woman IV sedation with Inj.Pentazocine (Fortwin) 30mg, and Inj.Phenergan 25 mg. En...
Uterine Inversion ‘O’ Sullivan’s hydrostatic pressure methodcan be attempted (?) if service provider isexperienced Do no...
Prevention Do not pull on the cord in the absence of auterine contraction. Always apply "counter-traction" with theother...
DELAYED PPHManagement• Give Inj. Oxytocin 10 IU I/M stat• Start IV infusion of 20 IU Oxytocin in 500 ml ofRinger Lactate /...
KEYPOINTS• Prevent PPH Practice AMTSL• Diagnose & treat PPH promptly if it occurs• Quick assessment of mother’s condition ...
THANK YOU
Dr Sunita Singal,SJH ND
Dr Sunita Singal,SJH ND
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    1. 1. PPH & ShockDr Sunita Singal,SJH ND
    2. 2. Objectives To detect PPH & assess degree of shock Identify types of PPH To develop skills and best practices formanagement of postpartum hemorrhage To describe strategies for prevention ofpostpartum hemorrhage
    3. 3. Haemorrhage is common Most common cause of maternal deathworldwide Probably accounts for more than 30-38% ofall maternal deaths Deaths from haemorrhage could often beavoided
    4. 4. Haemorrhage is often not recognized Blood loss is underestimated because inpregnancy signs of hypovolaemia do not showuntil the losses are large Mother can lose up to 30-35% of circulatingblood volume (2000 mls) before showing signsof hypovolaemia
    5. 5. PREVENTION STRATEGYFOR PPH
    6. 6. AMTSL: ACTIVEMANAGEMENT OF THIRDSTAGE OF LABOUR
    7. 7. The classical expectant management• Wait for the natural forces of labor to bringabout 3rd stage contraction and placentalseparation• Look for the signs of placental separation• Controlled cord traction to expel the placentaand membranes• Optional administration of Oxytocics
    8. 8. WHAT IS AMTSL :Active managementof 3rd stage• Oxytocic administration immediately afterdelivery of the baby so that the uterinecontractions & placental separation is notleft to the natural uncertain forces of labor• Controlled cord traction on perception of astrong uterine contraction with out waitingfor the actual signs of placental separation• Uterine massage to maintain the contraction
    9. 9. Benefits of AMTSL• Uterine atony accounts for 70-90% of all PPH cases• AMTSL reduces:Incidence of PPH by 60%Quantity of blood loss—thereby decreasing incidence &severity of anemiaEmergencies & related cost, transportThe use of blood transfusion
    10. 10. PPHaemorrhage - causes4Ts: Tone: uterine atony, Tissue: retained placenta or retained products, Tears: cervical or perineal, or ruptured uterus), Thrombin: coagulation disorder Coagulation disorders may also be associated withhaemorrhage
    11. 11. Symptoms& signsAssociatedfindingsProbablediagnosisImmediate PPHUterus soft &not contractedBleeding maybe continuousor Intermittent,ShockAtonic uterusImmediate PPHUteruscontractedBleeding isbright red andcontinuous(Completeplacentaexpelled)Traumatic PPH-tears in thecervix or vaginaPlacenta notdeliveredwithin 30 minof deliveryPPH may ormay not bepresentRetainedplacenta
    12. 12. Diagnosing the cause of PPHPortion of placentamissing ormembranes tornUterus relaxedPPHRetainedplacentalfragmentsUterine fundus notfelt on abdominalpalpationInverted uterusapparent atvulvaImmediate PPHInverted uterus
    13. 13. Shock due to Haemorrhage Shock is a life threatening condition thatrequires immediate, intensive treatment The presence of shock mean that there is aninadequate perfusion of organs & cells withoxygenated blood. There is some form ofcardiovascular compromise
    14. 14. Signs Present? When signs are there they are SIGNIFICANT Have a high suspicion and ACT QUICKLY!
    15. 15. Shock due to Haemorrhage –Signs Pale Confused Increased HR Reduced BP (late sign) Reduced urine output Obvious or hidden bleeding
    16. 16. Signs of shock Brain -unconscious, anxious, agitated andconfused, drowsy Skin - sweaty or cold and clammy Breathing - rapid Conjunctivae - pale Pulse - weak and fast >100/minute(sometimes “bounding pulse”) BP - low systolic < 90 mmHg(late sign) Kidney - poor urine output
    17. 17. Haemorrhage - management Follow the protocol ABCs C - replace the volume- stop the bleeding
    18. 18. Haemorrhage ABCs Circulation IV access by 2 large bore cannulae Send off blood samples Give iv fluids16G – GREY: 1 litre in 5 mins18G – GREEN: 1 litre in 10 mins20G – PINK: 1 litre in 15 mins22G – BLUE: litre in 30 mins
    19. 19. Shock- immediate actionCirculation Get iv access and send blood samples If pulse>100 / minute or BP< 90 mm Hg or heavy vaginalbleeding Give 1 l iv fluid over 20 minutes Give further 1 l over 30 minutes Review the situation and repeat if necessary Beware – if underlying anaemia or severe pre-eclampsia
    20. 20. How much fluid, How fast?• Volume of 3x the estimated loss as crystalloids(up to 4L) then as colloids• Give blood early – mistake often is too littletoo late! (So REFER to FRU early)• Replace as quickly as you can if patientshocked• Be guided by the patients signs and response(e.g. Pulse rate, level of consciousness)
    21. 21. Be aware of blood lost!Signs Blood lost ActionMild increase inpulse-700 mls Give iv fluidsIncrease in pulseand respiratory rate1500 mls Give iv fluidsFall in BP 2000 mls Give fluids andbloodCold, drowsy, veryhigh pulse, very lowBP2500 mls Large transfusionrequired
    22. 22. Shock- immediate action Ascertain the cause of haemorrhage Cover her and keep her warm Keep a careful record of input and output and drugsgiven If at a lower level facility, Prompt Referral to FRUafter resuscutation
    23. 23. Diagnosing the cause of PPHThe most important step in making a diagnosisof the cause of PPH is to keep a hand on thelower abdomen of the woman and feel forthe uterine tone
    24. 24. PPH – How to manageStepwise approach in case of uterineatony
    25. 25. Uterine atony Empty bladder Give Oxytocics Check for placenta completeness genital tract injury Rub uterus Bimanual compression Aortic compression Uterine tamponade
    26. 26. Management (Contd.) Massage uterus to expel clots and feel tosee that it is contracted—recheckintermittently Give oxytocin 10 units IM Give iv fluids Oxygen @6-8 L/ minute by mask
    27. 27. Oxytocic DrugsOxytocin Ergometrine/ 15-methylprostaglandin F2Dose and Route IV: Infuse 20units in 1 L at60 drop/min.IM: 10 unitsIM 0.2 mg IM: 0.25 mgContinuingDoseIV: Infuse 20units in 1 L at40 drop/min.Repeat 0.2 mgIM after 15 min.If required, give0.2 mg IM every4 hoursIM: 0.25 mgevery 15 min.Maximum Dose Not more than3 L of IVfluids5 doses 8 dosesPrecautions/ContraindicationsDo not giveas IV bolusPre-eclampsia,hypertension,heart diseaseAsthma
    28. 28. Bimanual Compression of Uterus Wearing sterile gloves,insert hand into vagina;form fist Place fist into anteriorfornix and apply pressureagainst anterior wall ofuterus
    29. 29. Bimanual Compression of Uterus(contd.) With other hand, press deeply into abdomenbehind uterus, applying pressure againstposterior wall ofuterus Maintaincompression untilbleeding is controlledand uterus contracts
    30. 30. Compression of Abdominal Aorta Apply downward pressure withclosed fist over abdominal aortadirectly through abdominal wall With other hand, palpate femoralpulse to check adequacy ofcompressionPulse palpable = inadequatePulse not palpable =adequate
    31. 31. Compression of Abdominal Aorta(Contd.)• Maintain compressionuntil bleeding iscontrolled
    32. 32. Uterine Tamponade (1)
    33. 33. Uterine Tamponade (2)Up to 500mls or until the uterus is contracted
    34. 34. RETAINED PLACENTA: MRP•IV oxytocin, oxygen, Empty bladder, CCT•If CCT not successful, on PV it can be felt incervix, grasp & remove.•If still cannot be removed, & Cx isdilated,MRP should be attempted giveplasma expanders, additionally•If placenta is retained & no bleeding referto FRU.
    35. 35. Traumatic PPH Episiotomy Perineal tears and lacerations Vaginal tears Cervical tears Uterine rupture Broad ligament hematoma Para-vaginal & Vulval hematoma
    36. 36. Follow-up care in atonic PPH• Monitor the vital signs( pulse, BP, RR)• every 10 min. for the first 30 mins,• every 15 mins. for the next 30 mins. & then• every 30mins. for the next 3-6 hours or until stable.• Palpate the uterine fundus to ensure that the uterusremains contracted.• Continue oxytocin infusion• Monitor the urinary output - should be more than 30ml/ hour
    37. 37.  Not a common condition Pulling on the umbilical cord in theabsence of a uterine contraction in aneffort to deliver the placenta can causeinversion of uterusAcute Uterine Inversion
    38. 38. Manual replacement of uterus Give the woman IV sedation with Inj.Pentazocine (Fortwin) 30mg, and Inj.Phenergan 25 mg. Ensure aseptic precautions Insert a hand into the vagina. Feel for thecervical rim. Reposit the uterus back, starting with the partthat comes out last (the fundus comes out firstand the portion of the uterus just above thecervix comes out last)
    39. 39. Uterine Inversion ‘O’ Sullivan’s hydrostatic pressure methodcan be attempted (?) if service provider isexperienced Do not remove the placenta, if attached touterus, before vaginal replacement of theuterus as it can lead to severe hemorrhage
    40. 40. Prevention Do not pull on the cord in the absence of auterine contraction. Always apply "counter-traction" with theother hand while carrying out controlled cordtraction. Do not apply fundal pressure to deliver thebaby or the placenta.
    41. 41. DELAYED PPHManagement• Give Inj. Oxytocin 10 IU I/M stat• Start IV infusion of 20 IU Oxytocin in 500 ml ofRinger Lactate / Normal saline at rate of 40-60drops / min• Suspect infection if fever and / or foul smellingvaginal discharge• Give first dose of antibioticsCap. Ampicillin 1 gm oralTab. Metronidazole 400 mg oralInj. Gentamycin 80 mg IM stat• Refer to FRU
    42. 42. KEYPOINTS• Prevent PPH Practice AMTSL• Diagnose & treat PPH promptly if it occurs• Quick assessment of mother’s condition &Tx of shock.• Identify the cause of PPH and manageaccordingly.• Timely referral to FRU where blood isavailable (after immediate management)
    43. 43. THANK YOU
    44. 44. Dr Sunita Singal,SJH ND
    45. 45. Dr Sunita Singal,SJH ND
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