Postpartum haemorrhage (PPH) is commonly defined as a blood loss of 500 ml or more within 24 hours after birth.
It affects about 5% of all women giving birth around the world.Globally, nearly one quarter of all maternal deaths are associated with PPH. In most low-income countries, it is the main cause of maternal mortality.
4. Globally, nearly one quarter of all
maternal deaths are associated with
PPH. In most low-income countries, it
is the main cause of maternal
mortality.
5. Massive obstetric haemorrhage
(MOH)
By
Volumes
By
Transfusion
WHO (2012) servere ppH= 1000ml
within 24 hours
RCOG (2016) major ppH = >2000ml
NHS England maternity
Dashboard metrics (2017) = 1500ml
Scottish CASMM 2500ml
Scottish CASMM 5 unit or
treatment for coagulopathy
UKOSS > 8 unit of blood within 24
hours of delivery
By rate of
Blood loss
BCSH (2006)
Blood loss 150ml per minute
Loss of 50% blood volume in 3 hours
Loss of 100% blood volume in 24
hours
MOH
6. Small women have small blood volumes.
Small loss produce great impact.
Blood volume varies with maternal size
7. PPH is an obstetric emergency that
can develop rapidly and
unexpectedly.
8. “Of particular concern is the rising rate of maternal death in
association with placenta accreta”.
10. Quantification of haemorrhage is
particularly difficult during
delivery and/or C/S .
Blood mixed with other fluid.
Large amount of blood may be
retained within the uterus .
11. Specific problems
of obstetric
patient
I. 20-30% increase in red cell mass
II. 50% increase in plasma volume
Women is in dilutional anaemia.
1.Tachycardia and hypotension –
misleading
2. Relative haemodilution and
increase cardiac out
3.Drop of Hb% and haematocrit.
12. Pregnancy is hyper
coagulable state
1. Plasma concentration of almost all the
coagulation factors - increase.
2. Decrease fibrinolytic system- increase
plasminogen activator inhibitor type-2.
3.Natural anticoagulant protein S
4. Thrombocytopenia
13. These changes result in a
shortening of prothombin time
(PT) and activated partial
thromboplastin time (APTT).
14. Cunnigham et al : Williams
obstetrics, 21st ed. 2001
Obstetrics
is bloody
business
16. Identification of
Risk factor
Prepregnancy
Ovulation induction/SET
Family planning
Pregnancy
Multipara, Multiple Pregnancy, placenta
previa .
Placenta acreta with previous history of
caesarean section.
Pregnancy with fibriod
Localization of placenta by USG
Identification and correction of anaemia
17. Prevention
Prophylactic use of Oxytocic drug during each
and every delivery.
Active management of third stage of labour.
Fourth Stage of labour
18. Prepare for PPH-Pre delivery
Personnel /Skilled man power
Drug/Equipment
Place of delivery
Blood ready at hand
Timing of delivery - Schedule for C/S
Consent for Hysterectomy
Type of anaesthesia
Two I/V line.
Modify Obstetric management
Place ment of Balloon cather inside uterine artery before C/S for embolisation
22. Not all haemorrhage is visible.
Visual estimation consistently underestimates large EBL
volumes by 30-50%.
Training can improve visual EBL skill but skill deteriorates
within 9 months of training.
Quantification of blood loss (QBL) significantly more accurate
than EBL.
QBL reduces risk of underestimation and treatment delay.
Seeing is not believing for blood loss
23. How to QBL Difficult task
Dr. Mohammad Abdul Quaiyum designed a
simple cotton and tissue paper birth mat to
identify post-partum haemorrhage. Photo:
Amy Yee
24. Rule of 30
30% loss of blood volume = moderate shock
-
Systolic BP fall by 30mm/hg
Heart rate rise by 30 beats/min
Respiration rate rise by 30 breaths/min
Urine output < 30ml/hr
Haemoglobin (Haematocrit) drop by
30%
26. Classification of Shock
Blood
loss
Stage-I
upto 15%
(750ml)
Stage-II
15-30%
(750-
1500ml)
Stage-III
30-40%
(1500-
2000ml)
Stage-IV
Over 40%
(over
2000ml)
BP Normal
(maintained By
vasoconstriction)
Increase
diastolic BP
Systolic
BP
< 100
Systolic
BP
< 70
Heart
Rate
Normal Slight
tachycordia
> 100bpm
Tachycardia
> 120bpm
Extreme
Tachycardia
>140bpm with
Weak pulse
Respiratory Normal Increase >20 Tachyponeic
> 30%
Extreme
Tachypnoea
Mental
state
Normal restless Altered
confused
Lethergy /coma
27. Skin Pallor Pate Cord
Clamuy
Increase
diaphoresis
Extreme
Diaphoresis
Mottling
possible
Capillary
refill
Normal Delayed Delayed Absent
Urine
output
Normal 20-30ml/hl < 20 ml/hl Negligible
Shock < 0.6 > 0.6 - < 1.0 ≥ 1.0 to
< 1.4
≥ 1.4
Base deficit ≥ 2.0 > 2 to 6.0 > 6.0-10 > 10
Classification of Shock
28. Complication of massive
postpartum haemorrhage
Hypovolaemic shock
Coagulopathy
Blood transfusion hazard
Lactation failure
Multi organ failure
Death
Anaemia
32. 1. Call for help.
2. High flow oxygen via face mask.
3. Head low down .
4. I/V access-Two large bore cannula (Green Cannula)
5. I/V fluid-warm 2L crystalloid +1.5 L colloid –[3500ml]
Resuscitation
and
immediate management
33. Fluid Type Comments
Normal saline Crystalloid Inexpensive readily
available.
Lactated Crystalloid Inexpensive readily
available.
Fluid Choices
Fluid Type Comments
? Albumin Colloid More expensive
Hydroxyethyl starch Colloid More expensive
Hypertonic saline with dextran Colloid Expensive
Blood Blood Expensive /clinical supply
Avoid dextrose containing fluids
34. 6. Send blood for -
a)grouping + cross matching
b)Laboratory - FBC, Coagulation screening
- renal and liver function rest
7. Foley’s catheter in situ
-Empty bladder
-monitor urine output .
8. O negative blood – better avoid.
9. Group specific cross match blood.
35.
36. What has been lost in PPH
Plasma volume – Required for perfusion
Replace after 1L loss (fluid replacement)
Red cells- Required to carry 02 to cell
Replace after 2L loss( Blood transfusion).
Coagulation factors / platelets for clots
Replace after 5L loss
(FFP, cryo, platelet)
37. 1. >50% blood volume loss without fluid
replacement will be fatal.
2. Hb < 50g/L despite fluid replacement
may cause organ failure/death.
The 50 rule
38. 1. Assess for shock and effectiveness of resuscitation
regular and repeated observation.
2. Respiratory rate and capillary refill useful signs.
3. Do not rely on systolic BP as main sign.
4. Measure and record Urine output.
5. Document resuscitation and treatment.
Monitor the resuscitation
39. Mental status Responsive to commands
Systolic BP 80-90m of Hg
Heart rate < 120/min
Pulse oximeter Saturation > 95%
Urine output Present
Targets of resuscitation
43. After 4U RBC give one unit of
FFP for each further unit of
blood.
Aggressive replacement of
coagulation factors may
improve outcome.
44. Target Ration
Hb > 8gm/100ml if less transfused RBCs.
INR < 1.5 if prolonged transfused fresh
frozen plasma.
Platelet > 50,000/mm3 if less -transfused platelet.
Fibrinogen > 1.5gm/L if less- transfused cryoprecipitate
1 unit/5kg.
Guideline to use of blood product
45. Coagulation monitoring to
prevent
dilutional coagulopathy
Conventional laboratory
test : 40-60 minutes
Point of care coagulation test
- Thrombo-elastography
&
Thrombo-elastometry
Viscoelastic properties of coagulation.
46. Intra operative blood
salvage.
Intra operative salvage
involves the collection of
blood from surgical field,
followed by washing and
filtration reinfusion to the
patient.
47. Treat the Cause
There may be more thanone!
Tone
70%
Tissue
9%
Thrombin
1%
Trauma
20%
48. H – Help and Hand over the uterine fundus for massage.
A – Assess (ABC) and resuscitation.
E – Establish Etiology and use of Ecbolics
HAEMOSTASIS
Oxytocin – 5 IU slow I/V may be repeat to 10 IU
Infusion - 30-40 unit in 500ml N/S over 4 hours
[30 drops/min]
Ergometrine – 0.5mg I/V or I/M
Carbitocin - 100gm IM / IV
Misoprostol – 1000 gm per rectal
Carboprost – 250mg I/M repeated every 15 min
total 2 mg – 8 doses
49. M - Massage the uterus
S - Shift to theatre/Higher center
(EUA and removal of retained product)
Shift to higher center – Apply Non
pneumatic anti shock garment.
Non pneumatic anti shock garment
50. T- Tamponade
-Several balloon can acts as tamponade
-CONDOM cather
A- Apply compression suture
( -lynch suture).
Tamponade test
Positive test - control
bleeding following
inflation
Negative test – indicates
Laceration/other.
51. S - Systematic pelvic devascularisation
I- Interventional radiology
S - Subtotal or total Abdominal hysterectomy
-Bilateral uterine artery ligation.
- Bilateral ovarian artery ligation.
-Internal iliac artery ligation.
52. The focus of treatment should be
preservation of the woman’s life rather
than preservation of her uterus.
Hysterectomy
sooner is better
than late.
55. Recombinant factor VII a
– 90 microgram/kg
2.
Ensure adequate level of fibrinogen and platelets
prior to administration of recombinant factor VIIa
COSTLY
It is useful in refractory PPH.
57. Additional challenges
Morbidly adherent placenta.
Unresponsive to treatment.
Non surgical PPH(Coagulopathy).
Refusal of blood and blood product.
58. Morbid Adherent placenta
Hysterectomy
Intentional retention of placenta.
Plan expectant management.
Triple P Technique for
preserving the uterus.
Balloon catheter in uterine artery
for embolisation.
59. Unresponsive to
resuscitation
A. Consider “BAD”
1. Broad ligament Haematoma.
2. Abdominal cavity (slippage of ligature).
3. Deeper planes- Para vaginal/suburethral
B. Consider “wash out” phenomena
Coagulopathy/
Recombinant activated factor VII
66. The position of a woman in any civilization is
an index of the advancement of that
civilization; is gauged best by the care given to
her at the birth of her child.
67. Mortality and morbidity due to substandard care 66%
( 2008 CMACE )
Too little done too late
Too little Awareness :
- Risk assessment
- Underestimation of blood loss
Too little responsibility:
(I/V fluid , Oxytocics, Blood Clotting factors
Too late action :
(Blood replacement, Decision for surgery and
to get skilled senior input and MDT input)
68. 1. Labour ward floor – PPH BOX
(Medicine, Fluid, Condom, Foleys Cather)
2. Monitor – Dash Board
(LESSON And LEARN,Practice improve)
FIRE DRILL
69. 3. Hospital protocol
I. Obs + Anae+ Haemotologist
II. Forms : (Blood order form, Resuscitation form, Transfer form,
Interventional radiological form).
III. Mandatory training- doctor ,nurse and midwife
(WORK SHOP IN YOUR INSTITUITION)
4. Feed Back :
- Congratulation to whole staff after successful management.
- Discussion after failure What we have missing.
5. Continuous learning and explore new things :
- Heat stable carbitocin
- Triple P technique
70. Summary
Be prepared
Recognize
Communication
Team Work
Resuscitation
Stop bleeding
postpartum/postoperative care