Tips to face the all too common problems like PPH in resource poor settings.

1. Challenges in Operative
Obstetrics in Rural Areas
Dr. Shantanu Abhyankar
Wai
Satara

2. II मातृ देवो भव IIगुरुवार, 18 जून
2015
3

3. DR.SHANTANU
Rural practice is a subspeciality
in itself…
• Low cost high risk practice.
• One wo/man show.
• You are forced to be alert, to be
innovative, to be an electrician, a plumber,
a nurse and a doctor all rolled into one
• Diploma in rural medical practice
• Dip. M.P.R.P.S.

4. DR.SHANTANU
Tight rope walk
• Poor paramedical support
• No health insurance
• Shoestring budgets and packages
• Monsoon economy
–Farmer suicides

5. OBSTETRICS IS BLOODY
BUISNESS
OPERATING SANS BLOOD

6. Where the mind is without fear: and the head is held high,
Where blood is free,
Where blood comes from voluntary healthy donors,
Where blood has been broken up into fragments by the refrigerated centrifuge,
Where the clear stream of blood and blood products from the RBTC has found its
way to the remotest storage centers,
Where tireless updating, CMEs & net surfing stretches its arms towards
perfection,
Where blood banking is led forward by thee into ever widening network and action,
Into that heaven of rural blood banking my father let my country awake.

7. THINK OF
AUTOLOUGUS
DONATION /
TRANSFUSION
• ANY WOMEN WITH NO OTHER
CONTRAINDICATION FOR DONATION &
Hb OF 10+ & PCV 35%+ MAY DONATE
BLOOD

8. THINK OF AUTOLOUGUS DONATION
/ TRANSFUSION
• ADVANTAGES
– NO MISMATCH
– NO TTD
– NO GRAFT V/S HOST
REACTION
– MEDICO LEGAL
SAFETY
• RISKS
– CLERICAL ERRORS
– SENSITIVITY TO
STABILISERS
– CONTAMINATION

9. A FRESH LOOK AT SOME
DEFINITIONS

10. HIGH RISK…IF
• DISTANCE FROM THE
NEAREST BLOOD BANK,
• NEAREST COLLEAGUE
• NEAREST REFERRAL
UNIT
IS MORE THAN AN
HOUR , IN TERMS OF
DURATION OF TRAVEL
EVERY CASE IS HIGH
RISK

11. ALLWAYS ON ALERT

12. Always on alert
• Hb for all
• and coagulation screen for all high risk cases
• BT CT PC PT ARE LATE MARKERS
• APTT TT FDP NOT AVAILABLE
• ICTERUS MEANS DOOM
• IF A CLOT FORMS AND DISSOLVES IT
SPELLS DOOM
• RESPONSIBLE RELATIVE

13. Always on alert
• Wide bore intracath in situ

14. Always on alert
• Callibrated drapes
to measure loss

16. Always on alert
• Active management of (all) stages of labor
• Consider Misoprostole P/R
– No magic pill this
– Takes 20 min
– Not very useful for massive loss

17. Always on alert
• Well equipped and well trained staff in the
labor room
• PPH box/equipment tray
• PPH display charts
• PPH drills

18. पी.पी.एच. झाले मारा बोंब ;
हाय ररस्कची करा नोंद.
II मातृ देवो भव IIगुरुवार, 18 जून
2015
19

19. दया हेड लो , दया ललथो टॉमी
II मातृ देवो भव IIगुरुवार, 18 जून
2015
20

20. कॅ थेटर घाला ब्लॅडरमधी
II मातृ देवो भव IIगुरुवार, 18 जून
2015
21

21. सोळा नंबर इंट्राकॅ थ ,
दोन्ही हातांना लावा स्टेट
II मातृ देवो भव IIगुरुवार, 18 जून
2015
22

22. घ्या भरपूर ब्लड सॅम्पल
II मातृ देवो भव IIगुरुवार, 18 जून
2015
23

23. मगच सुरु करा ररंगरचा नळ
II मातृ देवो भव IIगुरुवार, 18 जून
2015
24

24. मसाज करा , क्लॉट काढा,
टाके घाला झटपट
II मातृ देवो भव IIगुरुवार, 18 जून
2015
25

25. मसाज करा , क्लॉट काढा,
टाके घाला झटपट
II मातृ देवो भव IIगुरुवार, 18 जून
2015
26

26. मसाज करा , क्लॉट काढा,
टाके घाला झटपट
II मातृ देवो भव IIगुरुवार, 18 जून
2015
27

27. रक्त साकळतंय का बघा ,
नाहीतर येईल आफत.
II मातृ देवो भव IIगुरुवार, 18 जून
2015
28

28. चार ऍम््यूल पीटोसीन बाटलीत
टाका
II मातृ देवो भव IIगुरुवार, 18 जून
2015
29

29. इंजेक्शन मेथाजीन आय.व्ही. ठोका
II मातृ देवो भव IIगुरुवार, 18 जून
2015
30

30. दया प्रोस्टोडीन मांडीमधे
II मातृ देवो भव IIगुरुवार, 18 जून
2015
31

31. आणि चार सायटोटेक **मधे
II मातृ देवो भव IIगुरुवार, 18 जून
2015
32

32. ऑक्क्सजनचा चढवा मास्क
II मातृ देवो भव IIगुरुवार, 18 जून
2015
33

33. पेशंटला ठेवा गरम खास
II मातृ देवो भव IIगुरुवार, 18 जून
2015
34

34. रक्त चढवा , डोकं लढवा ,
रहा सदा दक्ष...
II मातृ देवो भव IIगुरुवार, 18 जून
2015
35

35. Always on alert
• Well equipped and well staffed labor room
• PPH box/equipment tray
• PPH display charts
• PPH drills

36. PPH BOX / TRAY

37. Always on alert
• Well equipped and well staffed labor room
• PPH box/equipment tray
• PPH display charts
• PPH drills

38. WHEN IT HAPPENS…
• ASSISTANTS AND COLLEAGUES MUST BE
TUNED TO THE SITUATION
– LABOUR WARD DRILLS
• RAISE AN ALARM 1
• LARGE BORE I/V ACCESS + BLOOD SAMPLES +2
• MASSAGE / UTEROTONICS (MDR) +1
• O2 BY MASK +1
• CATHETER
• HEADLOW
• EXAMINATION

39. PRE –OP PREPARATION
• PLAN YOUR INCISION
– ABDOMINAL
• MIDLINE VERTICAL FOR A CLASSICAL
OPERATION
• CONSIDER PREVIOUS SCARS
– UTERINE
• PLACENTAL POSITION
• VASCULARITY

40. PRE –OP PREPARATION
• BLOOD & BLOOD PRODUCTS
• AUTOLOGUS TRANSFUSION
– r Hu EPO IS NOW AVAILABLE
– IATROGENIC POLYCYTHEMIA IS
POSSIBLE

41. PRE –OP PREPARATION
• MATURITY CHECK
– MORE IMPORTANT IF COMPLICATIONS
HAVE SET IN LIKE GEST DM, PIH, IUGR
– EARLY USG
– L/S RATIO …. AMNIO…CHECK L BODIES
– BUBBLE STABILITY TEST
– PRE-TREATMENT WITH STEROIDS AND
MgSO4

42. WHEN IT HAPPENS…
• BACK UP POWER SUPPLY
• BACK UP SUCTION MACHINE
• HAVE STIRRUPS AVAILABLE SO THAT
FROG LEG POSITION (MIND YOU, NOT
LITHOTOMY) IS POSSIBLE

43. INTRA–OP
• INCISION
– EXCESSIVE BLEEDING IS NOTED RIGHT
FROM THE CUTANEOUS INCISION
– USE CAUTERY
– USE A STAY SUTURE ON THE LOWER
EDGE

44. INTRA–OP
• APPROACH THROUGH THE
PLACENTA?
• OR PAST THE PLACENTA?
(PREFFERED)

45. INTRA–OP
• AORTIC PRESSURE
• EXTERIORISE THE UTERUS
• PACK TIGHT WITH ALL YOUR MIGHT
WITH A HOT MOP
• FOUR VESSEL LIGATION
• CHECK
• SOS IIL
• SOS HYSTERECTOMY

46. INTRA–OP
• PROGRESSIVE DEVASCULARISATION
– OVARIAN VESSELS
– UTERINES
– INTERNAL ILIAC LIGATION

47. INTRA–OP
• POSTERIOR PLACENTA
– BLEEDING BED
• HOT MOPS & FIGURE OF EIGHT SUTURES

48. INTRA–OP
• ANTERIOR PLACENTA
– BLEEDING ‘ROOF’
• CIRCUMFERNTIAL SUTURES ALONG THE
EDGES

49. INTRA–OP
• B-LYNCH SUTURE
• HAYMAN SUTURE
– VERTICAL AND
HORIZONTAL
CERVICO-ISTHUMIC
SUTURES
• CHO MULTIPLE
SQUARE SUTURES
– HAVE DIAGRAMS IN
PPH KITS

50. INTRA–OP
• B-LYNCH SUTURE
• HAYMAN SUTURE
– VERTICAL AND
HORIZONTAL
CERVICO-ISTHUMIC
SUTURES
• CHO MULTIPLE
SQUARE SUTURES
– HAVE DIAGRAMS IN
PPH KITS

51. INTRA–OP
• PLACENTA ACCRETA
– DIAGNOSIS
• PRE OP
• INTRA OP
– Wring the uterine neck and chop off the uterus
• LEAVING PLACENTA IN SITU
– CLOSE MONITORING

52. INTRA–OP
• OBSTETRIC HYSTERECTOMY
– SUBTOTAL MAY NOT SUFFICE
– REMAIN INSIDE THE UTERINES
– CC CC SO TL
– CLAMP-CUT; CLAMP-CUT …. SPECIMEN
OUT… TRANSFIX & LIGATE

53. INTRA–OP
• PACKING
– PELVIS; POST HYSTERECTOMY

54. BATTLING BLOOD LOSS SANS
BLOOD.
• RESTORE AND MAINTAIN ADEQUATE
BLOOD VOLUME.
• WRAP BOTTLES IN BP CUFFS & PUMP
• CRYSTALLOIDS: THRICE THE ESTIMATED
BLOOD LOSS
• COLLOIDS AND STARCH SOLUTIONS ONLY
LATER

55. BATTELING BLOOD LOSS SANS
BLOOD
• OXYGEN, WARM BLANKETS,EVEN
PLASTIC GOWNS AND…
• WARM FLUIDS…USE MICROWAVE,
PUT BOTTLES IN HOT WATER
• HEATLOSS ADDS TO SHOCK AND DIC

56. VENOUS ACSESS
• 14 OR 16 G INTRAVENOUS CANNULA
• FEMORAL VEIN
• SUBCLAVIAN
• INT JUGULAR
– POST APPROACH
– ANT APPROACH
• Keep diagrams on the notice boards

58. VENOUS ACSESS
• 14 OR 16 G INTRAVENOUS CANNULA
• FEMORAL VEIN
• SUBCLAVIAN
• INT JUGULAR
– POST APPROACH
– ANT APPROACH
• Keep diagrams on the notice boards

60. VENOUS ACSESS
• 14 OR 16 G INTRAVENOUS CANNULA
• FEMORAL VEIN
• SUBCLAVIAN
• INT JUGULAR
– POST APPROACH
– ANT APPROACH
• Keep diagrams on the notice boards

62. VENOUS ACSESS
• 14 OR 16 G INTRAVENOUS CANNULA
• FEMORAL VEIN
• SUBCLAVIAN
• INT JUGULAR
– POST APPROACH
– ANT APPROACH
• Keep diagrams on the notice boards

64. BATTELING BLOOD LOSS SANS
BLOOD.
• MAINTAIN SUFFICIENT OXYGEN
CARRYING CAPACITY. KEEP HER
INTUBATED, IF NEED BE, TILL BLOOD
IS AVAILABLE.
• SECURE HEAMOSTASIS. AT TIMES
OPERATING WITHOUT BLOOD IS
SAFER THAN AWAITING BLOOD.

65. SOME PRACTICAL TIPS
• CUT A BOTTLE OF NS AT IT’S BASE & KEEP JUST
100ml OF NS
• ADD 1000iu INJ HEPARIN
• POUR SALVAGED BLOOD THROUGH 6 LAYERED
GAUSE
• MIX WELL
• INFUSE

70. PACK TIGHT WITH ALL YOUR
MIGHT

71. NASG

73. OTHER THERAPIES
• INTRA-OP CELL SALVAGE
• FACTOR VII
• SELECTIVE EMBOLISATION

76. RCOG GUIDELINES

77. DIAMOND POSITION
caaOkT PaaoJaIXana

78. Never change the brands of
injectables, medicines, i/v fluids
etc:
remember you are dealing
with persons wrapped in
white saris and not
‘nurses’

79. A place for everything and
everything in its place

81. RCOG GUIDELINES
• SYMPHISIOTOMY, O’SULLIVAN’S
TECHNIQUE FOR INVERSION OF
UTERUS… FORCEPS / CRANIOTOMY
FOR AFTER COMING HEAD…
GENUPECTORAL POSITION FOR
PROLAPSED CORD… MANUAL
ROTATION FOR POP… ARE FOR
REAL!!!

82. RCOG GUIDELINES
• ENSURE THE AVAILABILITY OF AN
ANESTHETIST & ONLY THEN DECLARE
THE NEED FOR CS

83. RCOG GUIDELINES
• IF THE TABLE DOES NOT TILT SHOVE
A BOTTLE OF SALINE UNDER THE
MATTRESS BELOW THE RIGHT HIP

84. RCOG GUIDELINES
• SHIFT THE PATIENT OUT OF THE
THEATER AS LATE AS POSSIBLE…

85. RCOG GUIDELINES
• AN OCCASIONAL UNINDICATED CS
DOEN NOT AN AUDIT MAKE!!!!
• ERR ON THE SIDE OF TOO SOON
RATHER THAN TOO LATE…

86. RCOG GUIDELINES
• THICK MSL… NO ANESTHETIST
• LLP
• ATROPINE
• AMNIOINFUSION
• OXYGEN, SODABICARD OF DOUBTFUL
EFFICACY

87. RCOG GUIDELINES
• BICEPS & TRICEPS ARE AT TIMES
SAFER THAN VACCUM & FORCEPS
• BEREADY TO USE THE MIDPELVIC
APPLICATION

88. RCOG GUIDELINES
• YOU ARE A TIRTIARY LEVEL
PHYSICIAN WORKING AT THE
PRIMARY LEVEL
• YOU NEED TO BE MORE SKILLED
THAN YOUR URBAN COLLEAGUE
• A JACK OF ALL AND A MASTER OF ALL

94. THANK YOU
• DR. VILAS PARAMANE
• DR. VIDYADHAR GHOTAWDEKAR
• DR. VINAY JOGALEKAR
• DR. SHIVDE (LONAND)
• DR. LATA PATIL
• DR. ULKA POL

95. LAMELLAR BODIES INSTEAD
OF L/S RATIO
• There is another factor to consider when addressing the relevance
of FLM testing: due to improvements in gestational age dating,
maternal administration of corticosteroids that accelerate fetal lung
maturity in at-risk pregnancies, and exogenous surfactant
replacement therapies, the number of newborn deaths due to RDS
has continued to decline over the last 15 years. Interestingly, most
laboratories have noted a decline in the number of FLM tests that
they perform each year. This trend reflects the decreased use of the
tests by obstetricians, many of whom indicate that the tests are no
longer needed for patient care.1 When one considers these facts in
light of the Bates study, it becomes legitimate—and provocative—to
ask the question: “Are tests of fetal lung maturity obsolete?”
18 June 2015 MATRU DEWO BHAVA