Hospital Based Surgical ProceduresIN POST PARTUM HAEMORRHAGE

1. Hospital Based
Surgical Procedures
IN POST PARTUM HAEMORRHAGE
DR SHARDA JAIN DR SANGEETA GUPTA DR JYOTI AGARWAL

3. Dr Jyoti Agarwal
MBBS (Gold Medalist)
M.D (Gynae & OBST )
FICOG, PGDMLS
Senior consultant & Director
* Lifecare Centre
* Lifecare IVF
 Ex President of D.G.F.(East)
 Treasurer : Delhi Gynaecologist Forum
 D.G.F. Certified Trainer for
* Infertility - IVF
* Ultrasound
* Colposcopy + Thermal Ablation
 Awards
* APJ Abdul kalam’s Appreciation Award DGF “East” 2015
* “THE TEACHERS EXCELLENCE AWARDS” DGF 2017
* APJ Abdul kalam’s Excellence Award DGF “East” 2020

4. “DYING TO GIVE LIFE
IS A REALITY” !

6. Post Partum HAEMORRHAGE
death is a biggest tragedy

7. How Do We Know
Which Women
Will Experience Complications of PPH?
7
WE DON’T

8. SHOCK : SYMPTOMS

9. CNP
ONSET – DEATH
INTERVAL ( WHO )
It is estimated that, if
untreated, death occurs
on average in:
12 hours from APH
2 days from Obstructed Labor
6 days from Infection
They gave me 5
units blood, but
it'was too late
24 hr EmOC
2 hours from PPH

11. Pathways to Maternal death …
Delay-1 Delay-2 Delay-3
Delay in
deciding
That there
is a
problem
Delay in
reaching
The
hospital
Delay in
initiating
Appropriate
care

12. THE FIRST DELAY : Decision Making
Institutional Delivery can
eliminate this 90% today
in India

13. Third DELAY : Hospital delay in
Starting Treatment
Institutional delivery +
ifrastructure +Training

14. INFRASTRUCTURE for
100% institutional Delivery
24 x 7 PHC

15. Hiring private
anaesthetists and
obstetricians to carry out
caesarian operations
Training MBBS doctors in
short term course in Life
Saving Anaesthesia Skills
and Emergency Obstetric
Care.
EmOC

16. INFRASTUCTURE
Delivery Points: Strengthened with
trained and skilled human resources,
infrastructure, equipment, drugs and
supplies, referral transport etc.
Obstetric HDU/ICU: In a high case
load tertiary care facilities across
country to handle complicated
pregnancies.
MCH Wings - Sanctioned at District
Hospitals/District Women’s Hospitals
as integrated facilities for providing
quality obstetric and neonatal care.

17. Prerequisites of
Hospital Based Procedures
ATONIC PPH
PATIENT STABLE
UTERINE TEMPONADE HAS FAILED
EXPERIENCED OBSTETRICIAN AVAILABLE

18. B-Lynch Suture

19. B-Lynch Suture
Use monocryl suture or vicryl
number 2
The – B LYNCH SUTURE aims to
exert continuous vertical
compression on the uterine
vascular and muscular system.
Professor
Dr. Christopher B-Lynch

20. B-Lynch Suture Pre- requisites
• Laparotomy
• uterine exteriorization and
• an opened uterine cavity are always
necessary.

21. B-Lynch Suture
Modification of this procedure are
also done

22. CHO
Suture

23. Cho multiple square compression
suture in placenta previa
Multiple square suture are used to cover the
whole body of the uterus and this may be
useful in placenta previa

25. Other conservative suture procedure
Vertical uterine compression
suture these suture are an
alternative to the B-Lynch
technique if no lower segment
cesarean incision is present
They may be placed without
opening the uterus
HAYMAN stitch

26. DGF conducts regular PPH workshops for
Gynaecologists across country
Request to be made on the following Phone No.
Dr Shashi lata Maheshwari : 9718990168
Ms Malti : 8826638849

28. UTERINE ARTERY EMBOLIZATION

29. Uterine artery embolization
facility only available in metros in INDIA
Remember : A patient must be sufficient stable
to transport to the angiography suite.
U.A. Embolization should be Considered Early ,
because it may take time to mobilize services .
Facility & trained invasive radiologist should
be available

30. UAE :
facility only available in metros in INDIA

31. UAE :
facility only available in metros in INDIA

32. Uterine artery embolization
WHEN EMBOLIZATION IS SUCCESSFUL, THE
PATIENT CAN RAPIDLY RECOVER WITHOUT
UNDERGOING ADDITIONAL SURGERY.
BENEFIT : Embolization not only saves the life
of the patient but also the uterus and adnexal
organ thus preserving fertility.

33. Stepwise De-Vascularization
in PPH

34. Stepwise de-vascularization in PPH

35. UTERINE ARTERY LIGATION
• Expose the lower part of the broad ligament.
• Feel for pulsations of the uterine artery near the junction of the uterus
and cervix.
• Pass a needle loaded with Catgut No 1-0 around the artery and through
2–3 cm of myometrium (uterine muscle) at the level where a transverse
lower uterine segment incision would be made. Tie the suture securely.
• Place the sutures as close to the uterus as possible because the ureter is
generally only 1 cm lateral to the uterine artery.
• Repeat on the other side.

36. UTERINE ARTERY LIGATION
• 1ST Step in systematic pelvic
devascularisation.
• uterine arteries which provide approximately
90% of uterine blood flow.
• Ligation of uterine arteries alone has success
rate of 80% in controlling PPH
All Gynaecologists doing LSCS should
learn this & follow this as a 1st
surgical skill after LSCS

37. Stepwise de-vascularization in PPH
Competent Obstetrician
The essential requirement is expertise and may
not be available in every unit . There is a need
for a competent obstetric surgeon who is
conversant and has expertise at pelvic
Gynaecological procedure , and who has
working knowledge of the pelvic anatomy
including the vascular and neurological supply of
the pelvic organs .

38. SITES FOR LIGATING UTERINE ARTERY

39. BITE TAKEN in musculature

40. Stepwise De-Vascularization in PPH
• Ovarian artery
directly arises
from aorta
• Anastomosis with
the uterine artery
in the region of
the uterine
aspect of the
utero ovarian
ligameent

41. Stepwise devascularization
Competent Obstetrician
Uterine artery ligation and the
Infundibulopelvic vessels can be ligated at the
junction of the tube meeting the uterus
without compromising ovarian blood supply .

42. UTERO OVARIAN ANASTOMOSIS
• If the artery has been torn, clamp and tie the
bleeding ends.
• Ligate the utero-ovarian artery just below the
point where the ovarian suspensory ligament
joins the uterus.
• Repeat on the other side.
• Observe for continued bleeding or formation
of hematoma
• Close the abdomen in layers.

43. Internal iliac artery ligation
Is highly technical
procedure.
expertise must be
available with 25%
gynaecologists
Dr. Sharda Jain
Secretory General DGF

44. Subtotal or total hysterectomy

45. Subtotal or total hysterectomy
Hysterectomy is the best immediate option
to save the hemorrhaging women’s life when
uterine atony is unresponsive to uterotonics
and where facilities for embolization are not
available and / or the obstetrician is not well
versed with the technical aspects of
conservative surgical procedure or iliac artery
ligation.

46. Subtotal or total hysterectomy
Subtotal hysterectomy is easy to perform ,
quick and is applicable in most cases of atonic
uterine bleeding .

47. TOTAL hysterectomy
Total hysterectomy may be needed in cases of
placenta previa accreta and cases of uterine
rupture involving the lower segment

48. RESORT TO HYSTERECTOMY
• Sooner rather than later
• Need to perform fast / RAPID
• No Use of saving the uterus and loosing the
mother

49. Surgical skills should be taught to
All Post Graduate &
Senior Residents when they leave
Medical College
Dr. Sharda Jain
Secretory General DGF