The document discusses damage control surgery (DCS) for postpartum hemorrhage (PPH). It provides: 1. DCS involves performing limited surgical interventions to control life-threatening bleeding and stabilizing the patient, then delaying definitive surgery until intensive care unit stabilization is achieved. 2. Indications for DCS include persistent bleeding, massive transfusion, hemodynamic instability, and the development of coagulopathy. 3. The key principles of DCS are rapid hemorrhage control, usually via packing, followed by resuscitation and correction of coagulopathy in the ICU before performing definitive surgery 48-72 hours later.

1. Damage Control Surgery
for Postpartum
Haemorhage
Prof. Rokeya Begum
Director
Surgiscope fertility center
&
Honorary Adviser
USTC
Bangladesh.

2. Any pregnant woman who will
delivered is at risk of
post-partum haemorrhage.

3. PPH – changing trends in obstetrics
Age old problem :
1. Anemia and nutritional deficiency
2. Three delays
3. Inadequate obstetric care
4. Safe delivery
5. Sound referral system

4. New challenges
1. Increased operative delivery
2. Adherent placenta
3. Change in obstetric demography
- Myoma
- Obesity
- Diabetes / Hypertension other co morbidities.
- Older age
- Coagulopathy Hereditary, acquired
- obstetric complications

5. Mortality high.
Too little and too late.
Do not get right treatment at appropriate time.

6. Losing patient after PPH or facing critical
illness has a long lasting demoralization of
leading obstetrician and hospital team.
Sadness creeps in like
A lifetime scar on the heart
The pain of which can be helped once
But the scars are forever….
-Tarannum Parveen

7. The vast majority of PPH related death occurs within four
hours of birth, so obstetric emergencies must be promptly
identified and managed.
Stop bleeding.
Several procedure.
Medical
Surgical

8. If you can fill the unforgiving minute with sixty
seconds worth of distance, run- Kipling

9. Sometime pursuit of total primary hemostasis is not possible
 DIC
 Large raw surface
 Venous plexuses
 Inaccessible area

10. Definitive aggressive surgery can worsen
bleeding and rendering the patient more morbid
and increase mortality.

11. Start organ dysfunction
 Hypothermia
 Metabolic acidosis lactic acidosis – hypoxia
 Coagulopathy
 Triad of death

12. At that point there is an alternative maneuvers in order
to provide enough time to achieve patient survival by
deferring her for a second definitive intervention in the
following days.

13. DCR – systematic approach to minimize hemorrhage prevent the deadly triad and
maximize the oxygenation of tissues.
Key principles of damage control resuscitation are –
 Permissive hypotension
 haemostatic resuscitation with limitation of crystalloid administration
 The use of massive blood transfusion protocols
 Physiological and biochemical stabilization in ICU.
Bleeding control

14. The term used to describe a series of surgical procedures performed in stages
during a period of patient hemodynamic instability. DCS consists of
performing limited surgical interventions to swiftly counteract life threatening
conditions with the definitive surgical procedure deferred until a period of
stabilization has been achieved in ICU.
Damage control surgery

15. What ((damage control)) does mean?

16. Decision for damage control surgery (DCS)
critical point –
 Early decision
 Time factor
Indication for damage control surgery
 Systolic BP <70mm of hrs.
 Body temp < 34C
 Maternal PH <7.1

17. Intraoperative indications for damage control surgery secondary to hemorrhage –
1. Venous bleeding not suitable for surgical control.
2. Persistent bleeding despite several transfusion of blood products (>10 unit of PRBC)
3. Massive transfusion
4. Increasing and continuous need for fluid due to an active nonarterial bleeding.
5. Hemodynamic instability requiring persistent vasopressor support of that result in the development
of ventricular arrhythmias.
6. Coagulopathy resulting from a combination of hypothermia (temperature < 35C) acidosis
(PH < 7.3) and loss of coagulation factors.
7. Duration of surgery >90min

18. Case I
• Multigravida
• Prolong labor
• C/S
• PPH
• Hysterectomy
• Bleeding not control
• Ozing from different sites
• Died in ICU.

19. Case II
• 3rd gravida
• P/H/S C/S
• C/S was done without knowing placenta previa
• Massive haemorrhage
• Hysterectomy with repair of bladder injury
• Intubation was done
• Bleeding not control
• Pelvic pack with surgical mop
• Drain tube : no - 20
- two

20. • Close the abdomen
• Patient in ICU with intubation
• 48 hrs. after
• Stabilization in ICU
• Remove the pack
• Evaluate any bleeding or injury
• Repair with drain in situ
• Extubate after one hour
• Patient recover
Case II

21. Case III
• 3rd gravida
• C/S was done for P/H/O c/s with placenta praevia
• During C/S – Bladder injury occurred which was
repaired by surgeon.
• Patient recovered
• Patient shift to ICU due to bleeding and deterioration
of patient general conditions after C/S.
• Intubation
• Laparotomy was done
• Hysterectomy and repair of bladder injury

22. • Uncontrol bleeding
• Pelvic pack
• Drain tube : no - 20
• Closure of abdomen
• ICU with intubation
• 48 hrs after relaparotomy .remove the pack
• Removal of pack or Mop difficult
because adherent with gut wall
• Close the abdomen
• Extubate in post operative ward.
Case III

23. Rapid control of bleeding
Surgical time is a determining factor in patient survival and
is recommended to be less than 90min since longer operating
time should be considered a predictor of adverse outcome
because of the onset of an irreversible physiologic insult
Hemorrhage can be control by means of packing.

24. Pack
Press
Pray

25. Abdominal packing which involves applying pressure to bleeding points
and compressing them against bony wall or facial resistance may be
necessary for these situation to prevent further blood loss and buy time
for resuscitation, coagulations correction and hemodynamic
stabilization.

26. Resuscitation - Intensive care unit
- Transfer to ICU

27. Team work is necessary for the management of PPH which
includes keeping the women hemodynamically stability while
concurrently locating and addressing the source of blood loss.
PPH guidelines typically advise a multidisciplinary strategy for
achieving efficient early control of bleeding.

28. The parameters are –
 pH
 Base deficits
 Lactate
 Hematocrite
 Coagulation
Follow up

29. Complications
a) Persistent bleeding > 400cc/hrs
- DIC
- bleeding sites need opening
b) Infection
c) Abdominal compartmental syndrome (ACS)

30. Due to the mechanical effect of packing and progressive, oedema of
abdominal tissues during the resuscitation process. Then is an increase of the
intra-abdominal pressure which is a common complication after pelvic
packing.
- Decrease venous return
- Decrease cardiac output
- Decrease renal perfusion
- Abnormality in mechanical ventilation.

31. Decompressions
- Repacking
- Adjuvant
- Nasogastric tube
- Rectal tubes
- Diuretics
- Use of muscle relaxant
- GI prokinetic agents

32. Definitive surgery
After stabilization of the physiological variables of the patient.
Safe to review the abdominal cavity
48-72 hours after

33. DCS
Part I – OR
• Control of hemorrhage
• Control of contamination
• Intraabdominal packing
• Temporary closure
Part III – OR
• Pack removal
• Definitive repair
Part II
• Core rewarming
• Correct coagulopathy
• Maintained hemodynamic
• Ventilatory support

34. How to avoid Adverse Situations in
Caesarean Section
• Why – needs c/s (Indication)
• Who – will perform the surgery (Surgical team)
• Where – does the indication allow to do it in any set up
(selection of OT – well equipped or not)
• When – does the surgery time appropriate with the
indication
• Whom – will act as rescuer and is he/she well
informed in advance by predicting difficulties
(Rescue team)
Remember
5WS
1. Predict – perioperative
adverse situations in advance.
2. Counsel – properly about the
complications that might appear
during or after surgery.
3. Select – competent team
members.
4. Choose OT – with maximum
availability of critical care
facilities (in high risk cases).
5. Inform Rescue Team – in
advance while predicting
complications.
6. Keep in touch – with the
patient party while referring the
patient.

35. 1. Successful results in control of refractory hemorrhage.
2. Control of haemorrhage can be possible in 98% cases.
3. This strategy should be implemented in the management
algorithm of major obstetric haemorrhage.
4.Obstetrician familiarizes with this technique in details.
Conclusion

37. Rescue committee