an update in Active management of the third stage of labour, including Prevention and Treatment of Postpartum Hemorrhage

1. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third Stage
of Labour: Prevention and Treatment
of Postpartum Hemorrhage
Hashem Yaseen MBBS
2nd
year OG resident KAUH

2. 12/3/2015 Hashem Yaseen MBBS
OutlinesOutlines
• IntroductionIntroduction
• Preventing PPHPreventing PPH
• Treatment of Established PPHTreatment of Established PPH
• Current issues in PPH careCurrent issues in PPH care

3. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction Preventing PPH
Treatment of
Established PPH
Current issues
in PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-surgical
Surgical
Radiological
Methods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

4. 12/3/2015 Hashem Yaseen MBBS
IntroductionIntroduction
Postpartum hemorrhage
• Is the leading cause of maternal
death worldwide
• occurs in 5% of all deliveries
• The majority of these deaths occur
within 4 hours of delivery, which
indicates that they are a
consequence of the third stage of
labour.

5. 12/3/2015 Hashem Yaseen MBBS
There are three broad areas in which the outcomes from PPH may be improved:There are three broad areas in which the outcomes from PPH may be improved:
prevention, treatment, and rescue (Figure 1). Prevention coversprevention, treatment, and rescue (Figure 1). Prevention covers
antenatal strategies, active management of the third stage of labour, andantenatal strategies, active management of the third stage of labour, and
treatments for retained placenta. PPH treatment covers both medicaltreatments for retained placenta. PPH treatment covers both medical
and surgical treatment, and PPH rescue therapies include intravenous fluids andand surgical treatment, and PPH rescue therapies include intravenous fluids and
blood transfusion, coagulation correction, and supportive care, such asblood transfusion, coagulation correction, and supportive care, such as
compression garmentscompression garments

6. 12/3/2015 Hashem Yaseen MBBS
Definitions OF PPHDefinitions OF PPH
• Normal blood loss during delivery
• The natural hemostatic mechanesims
• PPH is defined as blood loss:
> 500 ml following vaginal delivery ( nl 150 – 300 ml)
> 1000 ml following cesarean delivery ( nl: 800 – 1000)
• 10 % Drop in PCV
• Any bleeding results in hemodynamic instability
 The problem of definitions ???
• Primary (early) PPH -> withen 24 hrs of delivery (1st
6 hrs)
• Secondery ( late) PPH -> occuring between 24hrs & 6wks
after delivery.

7. 12/3/2015 Hashem Yaseen MBBS
HypovolemicHypovolemic ShockShock
• Clinical manifestations ??
• The blood loss is usually underestimated??
• Complications ??

8. 12/3/2015 Hashem Yaseen MBBS
Etiology of PPH & Risk factorsEtiology of PPH & Risk factors
for PPHfor PPH

9. 12/3/2015 Hashem Yaseen MBBS
Etiology of PPH & Risk factorsEtiology of PPH & Risk factors
for PPH cont’for PPH cont’

10. 12/3/2015 Hashem Yaseen MBBS
DDx for the cause of PPHDDx for the cause of PPH
• Soft boggy and large uterus with profuse vaginal
bleeding >>>
• Bright red before separation of the placenta >>>
• Mass increasing in size felt abdominally or in the
vagina >>>
• Bleeding is sever, bright red, no clots, uterus is well
contracted & skin ecchymosis >>>
• Cupping of the fundus >>>
• Non palpable fundus >>>
• Fever and tenderness >>>

11. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction Preventing PPH
Treatment of
Established PPH
Current issues
in PPH care
AMTSL PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-surgical
Surgical
Radiological
Methods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

12. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL
Two Methods of Third Stage Management
1. Physiologic (“expectant”) management
• Oxytocics are not used
• Placenta is delivered by gravity and maternal effort
• Cord is clamped after delivery of the placenta
2. Active Management
• Oxytocic is given
• Cord is clamped
• Placenta delivered by controlled cord traction (CCT) with counter-traction
on the fundus
• Fundal massage

13. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL
• Look for signs of placental separation:
1. lengthening of the umbilical cord outside.
2. The uterus becomes firm and globular.
3. The uterus rises in the abdomen.
4. A gush of blood.
• Delivery of membrane
By rotating the placenta about the insertion site
as it descends or grasping the membranes
with a clamp or artery forceps and drawn
down.

14. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL

15. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL

16. 12/3/2015 Hashem Yaseen MBBS
AMTSL
Evidence based
Four Cochrane reviews addressed prophylaxis in the third stage of labour for women delivering vaginally.The first (Active Versus Expectant Management in the Third Stage of Labour)27 included fivefive trials and found that active management (which included the use of a uterotonic, early clamping* of the umbilical cord and controlled traction for the delivery of the placenta) was associated with lower maternal blood loss and with reduced risks of PPH and prolonged third stage. However, active management was also
associated with an increased incidence of nausea,vomiting and raised blood pressure.A further Cochrane review included sevenseven trials comparing prophylactic oxytocin versus no uterotonic.28The conclusion was that oxytocin reduced the risk of PPH by about 60% and the need for therapeutic oxytocics by about 50%.

17. 12/3/2015 Hashem Yaseen MBBS
AMTSL
Evidence based study
A comparison of active management and expectant management of theA comparison of active management and expectant management of the
third stage of labour: a Swedish randomised controlled trialthird stage of labour: a Swedish randomised controlled trial

18. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL
• Timing of cord clamping:Timing of cord clamping:
Clamping of the umbilical cord is a necessary part of the third stage of labour. Its timing varies widely
throughout the world, early clamping being the predominant practice in Western countries.32
Physiological studies have shown that 25% to 60% of the fetal–placental circulation is found in
the placental circulation.33,34 Early cord clamping in term newborns results in a decrease of
20 to 40 mL/kg of blood, which is equivalent to 30 to 35 mg of iron. A delay in clamping,
causing increased neonatal blood volume, may lead to complications such as respiratory
distress, neonatal jaundice, and polycythemia.

19. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL
• Timing of placental deliveryTiming of placental delivery
Placental delivery is essential to allow the uterus to contract and thus reduce blood loss in the third
stage of labour. This process is completed within 5 minutes in 50% of deliveries and by 15
minutes in 90%. Failure of the placenta to be delivered in such a timely manner is a well-
known risk factor of PPH. The traditional definition of retained placenta includes failure of
placental delivery within 30 to 45 minutes and a requirement of intervention to assist with
delivery. One study published in 2006 concluded that the risk of PPH increases if the placenta
has not been delivered by 10 minutes, although research is needed to determine if the risk of
PPH can be reduced by intervening at this stage.

20. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL
• Placental cord drainagePlacental cord drainage
Placental cord drainage cannot be recommended as
a routine practice since the evidence for a
reduction in the duration of the third stage of
labour is limited to women who did not receive
oxytocin as part of the management of the
third stage. There is no evidence that this
intervention prevents PPH. (II-1C)

21. 12/3/2015 Hashem Yaseen MBBS
Active Management of the Third
Stage of Labour AMTSL
• Injection of the umbilical veinInjection of the umbilical vein
Intraumbilical cord injection of misoprostol (800 g) or
oxytocin (10 to 30 IU) can be considered as an alternative
intervention before manual removal of the placenta.
(II-2C)

22. 12/3/2015 Hashem Yaseen MBBS
Insight in RCOG SIP
• In healthy term babies, the evidence supports deferring clamping of the umbilical cord, as thisIn healthy term babies, the evidence supports deferring clamping of the umbilical cord, as this
appears to improve iron stores in infancy. Jaundice may be more common after deferred cordappears to improve iron stores in infancy. Jaundice may be more common after deferred cord
clamping but this management is likely to be beneficial as long as phototherapy for jaundice isclamping but this management is likely to be beneficial as long as phototherapy for jaundice is
available. This assessment of the evidence is concordant with the Cochrane review and theavailable. This assessment of the evidence is concordant with the Cochrane review and the
recommendations by NICE.recommendations by NICE.
• For term births, while the cord is intact the baby can be placed on the mother’s abdomen or chestFor term births, while the cord is intact the baby can be placed on the mother’s abdomen or chest
following a vaginal birth without influencing the volume of placental transfusion. Owing to thefollowing a vaginal birth without influencing the volume of placental transfusion. Owing to the
influence of gravity on placental transfusion, sensible advice is that while the cord is intact theinfluence of gravity on placental transfusion, sensible advice is that while the cord is intact the
baby should not be lifted higher than this. The timing of cord clamping should be routinelybaby should not be lifted higher than this. The timing of cord clamping should be routinely
recorded in medical notes.recorded in medical notes.
• The administration of intramuscular uterotonic drugs before cord clamping is unlikely to have aThe administration of intramuscular uterotonic drugs before cord clamping is unlikely to have a
substantive effect on placental transfusion.substantive effect on placental transfusion.
• For preterm births the evidence is less clear than for term births, although data from the trialsFor preterm births the evidence is less clear than for term births, although data from the trials
suggest potential benefit by deferred rather than immediate cord clamping. Strategies andsuggest potential benefit by deferred rather than immediate cord clamping. Strategies and
equipment for providing initial neonatal care and resuscitation at the woman’s bedside with theequipment for providing initial neonatal care and resuscitation at the woman’s bedside with the
cord intact should be developed further and evaluated.cord intact should be developed further and evaluated.
• Cord milking is an alternative to deferred cord clamping for preterm births, but requires furtherCord milking is an alternative to deferred cord clamping for preterm births, but requires further
evaluation of its benefits and risks before entering routine practice.evaluation of its benefits and risks before entering routine practice.

23. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction
Preventing
PPH
Treatment of
Established PPH
Current issues
in PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-surgical
Surgical
Radiological
Methods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

24. 12/3/2015 Hashem Yaseen MBBS
PPH medical prophylaxis
• Oxytocin:Oxytocin:
1. Oxytocin (10 IU), administered intramuscularly, is the preferred medication
and route for the prevention of PPH in low-risk vaginal deliveries. Care
providers should administer this medication after delivery of the anterior
shoulder. (I-A) *
2. Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL 150 mL per hour) is
an acceptable alternative for AMTSL. (I-B)
3. An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for
PPH prevention after vaginal birth but is not recommended at this time with
elective Caesarean section. (II-B) **
* recommended by the WHO, (NICE),16 and the International Federation of
Gynecology and Obstetrics (FIGO
**but causes a large, transient decrease in blood pressure when
administered this way, and so should be administered slowly with care

25. 12/3/2015 Hashem Yaseen MBBS
PPH medical prophylaxis
• Carbetocin:Carbetocin:
1. Carbetocin, 100 g given as an IV bolus over 1 minute, should be used instead of
continuous oxytocin infusion in elective Caesarean section for the prevention of PPH
and to decrease the need for therapeutic uterotonics. (I-B)
2. For women delivering vaginally with 1 risk factor for PPH, carbetocin 100 g IM
decreases the need for uterine massage to prevent PPH when compared with
continuous infusion of oxytocin. (I-B)
* resulting in rhythmic contractions of the uterus within 2 minutes, and lasting 1–2 hours
** some countries have already adopted it as their first-line recommended oxytocic, and a
large WHO study is underway to test its efficacy in comparison with oxytocin.

26. 12/3/2015 Hashem Yaseen MBBS
PPH medical prophylaxis
• Ergometrine and oxytocin/ergometrine (Syntometrine)Ergometrine and oxytocin/ergometrine (Syntometrine)
• Its administration causes an intense and sustained uterine contraction (in contrast to
the intermittent contractions caused by oxytocin).
• A systematic review of its use for prophylaxis shows it to reduce the PPH rate (when
used as part of the active management of the third stage of labour), compared with
physiological management.24
• There are associated increases in hypertension, vomiting, and pain associated with its
use, however, as well as an increase in retained placenta when it is administered
intravenously.25
• Ergometrine may be combined with oxytocin as a way of providing a sustained
contraction after the oxytocin has worn off.
• Systematic review shows Syntometrine to be slightly more effectiveslightly more effective than oxytocin
alone in preventing blood loss, but side effects are more common, with inreased levelsare more common, with inreased levels
of hypertension, nausea, and vomiting.26of hypertension, nausea, and vomiting.26
• The poor side effect profile has led to ergometrine being reserved for treatment ratherreserved for treatment rather
than universal prophylaxis.than universal prophylaxis.

27. 12/3/2015 Hashem Yaseen MBBS
PPH medical prophylaxis
• MisoprostolMisoprostol
• The long shelf life and oral administration of misoprostol make it attractive for use in
low-resource areas. It also has no effect on blood pressure or on the airways.
• Its most common side effect is to offset the temperature regulation of the body. self-
limiting within 3 hours, and respond rapidly to paracetamol.
• After many years of research into misoprostol for PPH prophylaxis, it appears that it
reduces postpartum blood loss,30 but that it is not as effective as oxytocin.
• Misoprostol may be of benefit in settings with poor health services.
• both the WHO and the FIGO guidelines suggest the use of a single prophylactic dose
of 600 lg of oral or sublingual misoprostol.

28. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction
Preventing
PPH
Treatment of
Established PPH
Current issues
in PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-surgical
Surgical
Radiological
Methods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

29. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established
PPH ~ Medical treatment• OxytocinOxytocin
• Evidence for its efficacy for PPH comes from trials on its prophylactic use.Evidence for its efficacy for PPH comes from trials on its prophylactic use.
• The WHO recommends intravenous oxytocin for first-line management, with ergometrine (with orThe WHO recommends intravenous oxytocin for first-line management, with ergometrine (with or
without oxytocin) or a prostaglandin drug (including misoprostol, 800 lg sublingually) as a second linewithout oxytocin) or a prostaglandin drug (including misoprostol, 800 lg sublingually) as a second line
• MisoprostolMisoprostol
• Evidence -> studies show that oxytocin is more effective than misoprostol for the treatment of PPH if itEvidence -> studies show that oxytocin is more effective than misoprostol for the treatment of PPH if it
has not been previously given as prophylaxis, and that there is no benefit in giving misoprostol ifhas not been previously given as prophylaxis, and that there is no benefit in giving misoprostol if
oxytocin has already been used. For units that already stock oxytocin, therefore, there is little benefit inoxytocin has already been used. For units that already stock oxytocin, therefore, there is little benefit in
also stocking misoprostol.also stocking misoprostol.
• Tranexamic acidTranexamic acid
• it would reduce bleeding irrespective of whether it came from uterine atony or lacerations. Non-obstetricit would reduce bleeding irrespective of whether it came from uterine atony or lacerations. Non-obstetric
surgical studies have shown it to be effective in reducing blood loss, as have a few small obstetric trialssurgical studies have shown it to be effective in reducing blood loss, as have a few small obstetric trials
• ErgometrineErgometrine
• There is minimal evidence regarding the use of ergometrine for the treatment of PPH, although it isThere is minimal evidence regarding the use of ergometrine for the treatment of PPH, although it is
included in all the major PPH guidelines. Its inclusion is justified on the basis of its demonstrated efficacyincluded in all the major PPH guidelines. Its inclusion is justified on the basis of its demonstrated efficacy
in the prophylaxis trials.in the prophylaxis trials.

30. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established
PPH ~ Medical treatment
Hemabate
methergine

31. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction
Preventing
PPH
Treatment of
Established PPH
Current issues
in PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-
surgical
Surgical
Radiological
Methods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

32. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established
PPH ~ Non-surgical• TamponadeTamponade
 The quickest method of tamponade is
with bimanual compression of the uterus.
 Bakri SOS tamponade balloon catheter
 Sengstaken Blakemore esophageal catheter
 Foley catheter filled with 60 to 80 mL
 Rusch hydrostatic urologic balloon
 Hydrostatic condom catheter
 Uterine packing
* continued oxytocin infusion may be required to maintain uterine tone.* continued oxytocin infusion may be required to maintain uterine tone.
*Prophylactic antibiotic therapy should be considered.*Prophylactic antibiotic therapy should be considered.
*The balloon can be left in place for 8 to 48 hours and then gradually*The balloon can be left in place for 8 to 48 hours and then gradually
deflated and removed.deflated and removed.
*Analgesia and anaesthesia are not specifically mentioned in*Analgesia and anaesthesia are not specifically mentioned in
a number of the studies identifieda number of the studies identified

33. 12/3/2015 Hashem Yaseen MBBS
Commercially Available Balloon
Tamponades in Use
Bakri
$250 per device
Sengstaken–Blakemore
$220 for two devices Rusch hydrostatic
$77 (quoted £50)
BT-CATH
$200 per device
These commercially available devices are prohibitively expensive
Source: Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009;116:748-757

34. 12/3/2015 Hashem Yaseen MBBS
Inflate Condom with
water till no further
bleeding is occuring
(usually about 300-
500 mls )
UTERUS
Foleys Catheter
Condom
String
Apply clamp to keep water within
Condom after inflation
Giving set
Water/NS
OR
syringe
THE CONDOM TAMPONADE
Clean
water

35. 12/3/2015 Hashem Yaseen MBBS
Developed in Bangladesh
by Ashkter and Team
When should we not use the balloon?When should we not use the balloon?
1.1. Arterial bleeding requiring exploration andArterial bleeding requiring exploration and
ligation or angiographic embolization.ligation or angiographic embolization.
2.2. Cases indicating hysterectomy.Cases indicating hysterectomy.
3.3. Where uterine rupture is suspectedWhere uterine rupture is suspected
4.4. Cervical cancer.Cervical cancer.
5.5. Disseminated Intravascular CoagulationDisseminated Intravascular Coagulation
(DIC)(DIC)

36. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction
Preventing
PPH
Treatment of
Established PPH
Current issues
in PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-
surgical
Surgical
RadiologicalRadiological
MethodsMethods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

37. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established PPH ~
Radiological Methods
Percutaneous transcatheter arterial embolization :Percutaneous transcatheter arterial embolization :
is an option when there is active bleeding in a hemodynamically stable woman and beforeis an option when there is active bleeding in a hemodynamically stable woman and before
surgical intervention. A review of the literature found success rates of 100% after 49surgical intervention. A review of the literature found success rates of 100% after 49
vaginal deliveries and 89% after 18 Caesarean sections. This technique preserves thevaginal deliveries and 89% after 18 Caesarean sections. This technique preserves the
uterus and adnexa and thus fertility. The procedure requires rapid access to imaginguterus and adnexa and thus fertility. The procedure requires rapid access to imaging
technology and interventional radiologists, which is not available to all centres.technology and interventional radiologists, which is not available to all centres.
AdvantagesAdvantages
Preserves FertilityPreserves Fertility
Useful in Haemorrhage associated with Placenta praeviaUseful in Haemorrhage associated with Placenta praevia
DisadvantagesDisadvantages
• Requires 24hr availability of radiological expertise.Requires 24hr availability of radiological expertise.
• Patients must be stablePatients must be stable
• Complications include: Necrosis of uterine wall, contrast adverse effects, local haematoma formationComplications include: Necrosis of uterine wall, contrast adverse effects, local haematoma formation

38. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction
Preventing
PPH
Treatment of
Established PPH
Current issues
in PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-
surgical
SurgicalSurgical
Radiological
Methods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

39. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established
PPH ~ Surgical
is an option when there is active bleeding in a hemodynamically stable Surgical
techniques such as ligation of the internal iliac artery, compression sutures,
and hysterectomy should be used for the management of intractable PPH
unresponsive to medical therapy. (III-B)
1.1. Haemostatic brace suturing (such as the B-Lynch suture, Cho suture)Haemostatic brace suturing (such as the B-Lynch suture, Cho suture)
2.2. Bilateral ligation of uterine arteries.Bilateral ligation of uterine arteries.
3.3. Bilateral ligation of internal iliac arteries by an experienced operatorBilateral ligation of internal iliac arteries by an experienced operator
4.4. Peripartum Hysterectomy.Peripartum Hysterectomy.

40. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established
PPH ~ Surgical
the B-Lynch suturethe B-Lynch suture

41. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established
PPH ~ Surgical
Cho sutureCho suture

42. 12/3/2015 Hashem Yaseen MBBS
Treatment of Established
PPH ~ Surgical
Multiple U-suture.Multiple U-suture.Hayman sutureHayman suture

43. 12/3/2015 Hashem Yaseen MBBS
Outlines
Introduction
Preventing
PPH
Treatment of
Established PPH
Current issuesCurrent issues
in PPH carein PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-
surgical
Surgical
Radiological
Methods
Non-PneumaticNon-Pneumatic
Anti-ShockAnti-Shock
Garment (NASG)Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

44. 12/3/2015 Hashem Yaseen MBBS
NASG - Non-pneumatic Anti-shock
Garment
• Physiology – shunts blood to vital organs (anti-Physiology – shunts blood to vital organs (anti-
shock)shock)
• During delays, provides up to 48hrs stabilityDuring delays, provides up to 48hrs stability
• In 2008 growing clinical evidence for PPH use.In 2008 growing clinical evidence for PPH use.
• Expensive, poor quality controlsExpensive, poor quality controls
• In 1991 FDA cleared medical deviceIn 1991 FDA cleared medical device
• NASG is a simple device that counteracts shockNASG is a simple device that counteracts shock
and decreases blood loss by applying directand decreases blood loss by applying direct
counter pressure to the lower parts of thecounter pressure to the lower parts of the
body.body.
• Developed by NASA 20+ yrs agoDeveloped by NASA 20+ yrs ago
• Useful as a first aid tool that Keeps womanUseful as a first aid tool that Keeps woman
alive during prolonged transportationalive during prolonged transportation
Current issues in PPH care

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• The NASG was developed as a way of maintaining a soldier’s blood pressureThe NASG was developed as a way of maintaining a soldier’s blood pressure
following traumatic injury during transfer from the battlefield to the hospital.following traumatic injury during transfer from the battlefield to the hospital.
• garment is wrapped tightly around the legs and abdomen, squeezing blood fromgarment is wrapped tightly around the legs and abdomen, squeezing blood from
the superficial vessels into the central vessels, and compressing the uterus.the superficial vessels into the central vessels, and compressing the uterus.
• In animal studies the translocation of blood is up to 30% of the total bloodIn animal studies the translocation of blood is up to 30% of the total blood
volume.volume.
• The garment also reduces the available intravascular space, which in turn raisesThe garment also reduces the available intravascular space, which in turn raises
the blood pressurethe blood pressure
• The WHO recommends its use as a temporising measure until appropriate care isThe WHO recommends its use as a temporising measure until appropriate care is
availableavailable..

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Outlines
Introduction
Preventing
PPH
Treatment of
Established PPH
Current issuesCurrent issues
in PPH carein PPH care
AMTSL
PPH medical
prophylaxis
Timing of cord
clamping
Timing of
placental
delivery
Placental cord
drainage
Injection of the
umbilical vein
Insight in
RCOG SIP
Definitions OF
PPH
Hypovolemic
Shock
Risk factors
for PPH
Etiology of PPH
DDx
Oxytocin
Ergometrine and
oxytocin/ergometrine
(Syntometrine)
Misoprostol
carbetocin
Medical
treatment
Non-
surgical
Surgical
Radiological
Methods
Non-Pneumatic
Anti-Shock
Garment (NASG)
Assessment
based on
blood-loss
volumes
Evidence based
study
Tamponade
THE BRASSS-V
DRAPE

47. 12/3/2015 Hashem Yaseen MBBS
Assessment based on blood-loss volumes
• Measuring Blood LossMeasuring Blood Loss
A key step to EFFECTIVE TREATMENT…..A key step to EFFECTIVE TREATMENT…..
• The Diagnosis of PPH is based on the amount of blood loss (>500ml).The Diagnosis of PPH is based on the amount of blood loss (>500ml).
Underestimation leads to delayed intervention.Underestimation leads to delayed intervention.
• Visual estimated amounts of blood loss are notoriously far from accurate byVisual estimated amounts of blood loss are notoriously far from accurate by
as much as 30-50%: especially for very large amounts.as much as 30-50%: especially for very large amounts.
• In one study the incidence of PPH by visual estimation were 5.7% (500ml) andIn one study the incidence of PPH by visual estimation were 5.7% (500ml) and
0.44% (1000ml) whereas direct measurement showed the true incidences to0.44% (1000ml) whereas direct measurement showed the true incidences to
be 27.6 and 3.51% respectively.be 27.6 and 3.51% respectively.
Current issues in PPH care

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THE BRASSS-V DRAPE
A low cost calibrated plastic
blood collection drape.

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BRASSS-V DRAPE:
Direct measurement of blood loss (PPH(

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Advantages of Brasss-VAdvantages of Brasss-V
• Simple and practical
• Low cost: ( Plastic)
• Accurate:
• Objective
• Can be used in a wide range of settings
• Provides a hygienic delivery surface

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blood productblood product transfusiontransfusion
• Crystalloid Up to 2 litres Hartmann’s solutionCrystalloid Up to 2 litres Hartmann’s solution
• Colloid up to 1–2 litres colloid until blood arrivesColloid up to 1–2 litres colloid until blood arrives
• Blood CrossmatchedBlood Crossmatched
• If crossmatched blood is still unavailable, give uncrossmatchedIf crossmatched blood is still unavailable, give uncrossmatched
• group-specific blood OR give ‘O RhD negative’ bloodgroup-specific blood OR give ‘O RhD negative’ blood
• Fresh frozen plasma 4 units for every 6 units of red cells or prothrombinFresh frozen plasma 4 units for every 6 units of red cells or prothrombin
time/activated partial thromboplastin time > 1.5 x normal (12–15 ml/kgtime/activated partial thromboplastin time > 1.5 x normal (12–15 ml/kg
or total 1 litres)or total 1 litres)
• Platelets concentrates if PLT count < 50 x 109Platelets concentrates if PLT count < 50 x 109
• Cryoprecipitate If fibrinogen < 1 g/lCryoprecipitate If fibrinogen < 1 g/l

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the management considerations forthe management considerations for
Postpartum HaemorrhagePostpartum Haemorrhage
• Effective team management of PPHEffective team management of PPH
involvesinvolves
1.1. recognition,recognition,
2.2. communication,communication,
3.3. resuscitation,resuscitation,
4.4. monitoring andmonitoring and
5.5. investigation andinvestigation and
6.6. directed treatmentdirected treatment

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• How should secondary PPH be managed?How should secondary PPH be managed?
Secondary PPH is usually associated withSecondary PPH is usually associated with
endometritis (with or without retained products ofendometritis (with or without retained products of
conception). Conventional treatment usually includesconception). Conventional treatment usually includes
antibiotic therapy and, uterotonics in some cases. Inantibiotic therapy and, uterotonics in some cases. In
situations of excessive or continued bleeding surgicalsituations of excessive or continued bleeding surgical
intervention, particularly the evacuation of retainedintervention, particularly the evacuation of retained
products, should be considered, irrespective ofproducts, should be considered, irrespective of
ultrasound findings.ultrasound findings.

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ConclusionsConclusions
• Be preparedBe prepared
• Practice preventionPractice prevention
• Assess the lossAssess the loss
• Assess the maternal statusAssess the maternal status
• Resuscitate vigorously and appropriatelyResuscitate vigorously and appropriately
• Diagnose the causeDiagnose the cause
• Treat the causeTreat the cause

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REFERENCES
1.1. Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum HemorrhageActive Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage ;The;The
Society of Obstetricians and Gynaecologists of Canada, clinical practice guideline on PPH, published in AprilSociety of Obstetricians and Gynaecologists of Canada, clinical practice guideline on PPH, published in April
2010, No 2352010, No 235
2.2. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?
BJOG 2015; 122:202–212.BJOG 2015; 122:202–212.
3.3. Clamping of the Umbilical Cord and Placental Transfusion, Scientific Impact Paper No. 14, February 2015, theClamping of the Umbilical Cord and Placental Transfusion, Scientific Impact Paper No. 14, February 2015, the
Scientific Advisory Committee of the RCOG.Scientific Advisory Committee of the RCOG.
4.4. WHO guidelines for the management of postpartum haemorrhage and retained placenta, World HealthWHO guidelines for the management of postpartum haemorrhage and retained placenta, World Health
Organization 2009Organization 2009
5.5. Management of Postpartum Haemorrhage (PPH), the RANZCOG Board and Council, March 2014Management of Postpartum Haemorrhage (PPH), the RANZCOG Board and Council, March 2014
6.6. RCOG Green-top Guideline No. 52. Prevention and management of postpartum haemorrhage. 2009.RCOG Green-top Guideline No. 52. Prevention and management of postpartum haemorrhage. 2009.
7.7. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009;116:748–757.Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009;116:748–757.
8.8. The surgical approach to postpartum haemorrhage. The Obstetrician & Gynaecologist 2009;11:231–238.The surgical approach to postpartum haemorrhage. The Obstetrician & Gynaecologist 2009;11:231–238.
9.9. Jangsten E, Mattsson L, Lyckestam I, Hellstro¨m A, Berg M. A comparison of active management and expectantJangsten E, Mattsson L, Lyckestam I, Hellstro¨m A, Berg M. A comparison of active management and expectant
management of the third stage of labour: a Swedish randomised controlled trial. BJOG 2011;118:362–369.management of the third stage of labour: a Swedish randomised controlled trial. BJOG 2011;118:362–369.