CCON

1. TRANSFER OF PATIENT
WITH PPH
MR.RAVI KUMAR
B.SC NURSING 1ST
YEAR
CCON
PPH Module

2. When to transfer the patient with
PPH?
 From PHC to First Referral unit:
Clinical assessment Class I / Retained placenta /
Traumatic PPH
 From Nursing home with OT to Hospital with
HDU & ICU:
Uncontrolled Class II
 From Labor room to OT:
Class II / Retained placenta / Traumatic PPH
(Do not wait till Class III & IV)

3. Prerequisites for Transfer
 Informed consent
 Anti shock Garment (NASG)
 Check availability of bed/Doctor in the referral
hospital
 Referral documents
 Indwelling catheter with Urosac
 Vaginal pack in traumatic PPH
 Tamponade in atonic PPH
 Record presence of Pack/Tamponade – Do not
remove until destination

4. Referral Documents
 Antenatal Record with risk factors
 Intranatal events:
Delivery notes: Vaginal/Instrumental /
Caesarean section
Time of delivery of Baby/Placenta
Episiotomy/Vaginal laceration/Cervical tear
 Investigation results
 Sequence of events
 Medication administered with time & dose
 Fluids administered
 Condition on Transfer

5. On transfer
 Nasal Oxygen on flow
 Two IV lines (#16/18) with fluid on flow
 Nurse or Doctor & Patient’s able attendant
to accompany

6. Non-Pneumatic Anti Shock Garment
(NASG)

7. NASG (Life Wrap)
 It applies pressure on the legs & abdomen
 Blood returns to vital organs curbing internal
bleed
 Stabilizes BP until patient reaches appropriate
hospital
 Easy to apply
 Application time takes < 60 seconds in trained
hands

8. How does NASG work?
 It is a First Aid
 Controls bleeding through direct pressure
 Auto transfusion of blood in upward
direction
 Ball in abdominal segment applies focused
pressure to uterus
 Circumferential pressure on lower half of
the body reduces the total vascular space
 Vital organs get increased blood supply &
oxygenation
 Stabilization of patient during transport

9. How does NASG work?

10. About NASG
 NASG is light weight (1500 G)
 Compression suit made of Neoprene
 Six segments enclosing ankle, calves, thigh,
pelvis & abdomen
 Velcro fastenings to keep garment tight
 A small foam ball in the abdominal segment
applies pressure on the uterus
 Markings on the sections show how to apply

11. About NASG
 Correct tight application supplies 20 to 40 mm
Hg of circumferential pressure to lower body
effectively reversing hypovolemic shock
 Can be easily packed back into carry bag

12. NASG (Life wrap)

13. Applying NASG
Step 1:
 Place NASG under the woman with the top at
the level of lowest rib
 Close segment 1 tightly around ankle on both
sides
 Snap it until you hear a sharp sound
Step 2:
 Close segment 2 around calf muscle
 Leave the knee joint free

14. Applying NASG
 Step 3:
 Apply segment 3 around the thighs
 Step 4:
 Apply segment 4 all around the woman with
the lower edge at the level of pubic bone

15. Applying NASG
 Step 5:
 Place segment 5 with pressure ball directly
over umbilicus
 Close the NSAG using segment 6
 Only one person should close segment 4 &
5
 Should not be too tight to
restrict breathing

16. Applying NASG
 Step 6:
 Ensure patient is breathing normally after the
application
 In case of uterine atony administer uterotonics
& massage the uterus without removing the
NASG
 NASG is flexible enough to allow the
massaging

17. Vaginal Procedures with NASG in
situ
 Pelvic examination
 Lithotomy position
 Repair of episiotomy /
Perineal tear / Vaginal
laceration / Cervical tear
 MRP
 Bimanual compression
 D&C / D&E / MVA

18. Surgery with NASG in situ
 Laparotomy (Keep segments 1,2&3 in situ and
open pelvic & abdominal segments 4,5&6 just
prior to incision)
 Steep Trendelenberg position
 Operate quickly
 Replace segment 4, 5 & 6 after procedure

19. Special situations
 Obese women
 Short stature
 Need for defecation
 Replacing soiled NASG

20. Questions to ask the patient
 Are you comfortable?
 Any breathing difficulty?
 Is it hot inside NASG?
 Do you feel itchy?

21. When to remove NASG?
 Patient must be stable for 2 hours
 Bleeding <50 ml/hr
 Pulse <100 BPM
 Systolic BP 90-100 mm Hg
 Hb >7G%
 Patient conscious & aware

22. How to remove NASG?
 Remove segment 1 & wait for 15 mts
 Check pulse & BP
 If pulse rate increases >20 BPM or BP falls by
20 mm Hg: Reapply segment 1
 If vitals stable remove segment 2
 Follow same principles till removal of segment
6

23. Do not remove NASG before all
vital signs are restored
Early removal of NASG can be
dangerous or even fatal

24. Caution
 If BP falls by 20 mm Hg or Pulse increases by
20 BPM after removal of any segment, rapidly
replace all segments
 Consider need for crystalloids / Blood
 If recurrent bleeding, determine source and
arrest

25. Storing NASG
 Clean NASG with running water & disinfectant
and dry
 Keep folded NASG in a clear plastic bag
 Store NASG in a place where it is visible &
accessible
 Always store at the same place
 Ensure every one knows place of storage
 Storage place should be displayed prominently
 The referral center must send a replacement
NASG after receiving the patient

26. Relative contraindications
 Cardiac failure
 Pre existing Mitral stenosis / Pulmonary edema
 Advanced pregnancy with live fetus (APH)
 Abdominal evisceration
 Open pelvic fracture

27. Principles to be observed
 One person alone can apply NASG
 Two persons needed when patient is
unconscious
 Urine output should be measured
 Ensure airway protection & Prevent aspiration
 Ensure one on one nursing care

28. Advantages of NASG
 50-78% Reduction in blood loss
 50-55% Reduction in Maternal Mortality &
related Morbidity
 WHO includes NASG in recommendations
 Cost effective
 Reusable

29. World Scenario 2013
Used in 16 Countries
UK & USA
Remote Rural areas
Jehova’s witness
Zambia &
Zimbabwe
Peri urban
centers
Tamil Nadu
All levels
Ambulance
#108