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
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
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
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
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