Postpartum haemorrhage (PPH) is a major cause of maternal mortality. The main causes are uterine atony (80%), trauma (20%), and coagulopathy (rare). Clinical PPH is blood loss >500mL after vaginal delivery or >1000mL after c-section. Treatment involves monitoring vitals, IV fluids, uterotonics like oxytocin and misoprostol, bimanual compression, and blood transfusion. For refractory cases, procedures like balloon tamponade, ligation of uterine arteries, or hysterectomy may be needed. Prevention focuses on risk assessment, active management of third stage of labor, and treatment of secondary PPH if bleeding reoccurs after 24
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
Obstetric emergency which can kill instantly !! - PPH presenting to ED, so what is the role of Emergency Dept ? The most basic presentation of Obstetric emergency and how to tackle it? Being an emergency physician, obstetrics is always challenging! Keep yourself updated with Obstetric emergency.
complcations of third stage of labour, includes PPH, Inversion of uterus, retained placenta, placenta accreta, increta, percreta, amniotic fluid embolism
Obstetric emergency which can kill instantly !! - PPH presenting to ED, so what is the role of Emergency Dept ? The most basic presentation of Obstetric emergency and how to tackle it? Being an emergency physician, obstetrics is always challenging! Keep yourself updated with Obstetric emergency.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
3. PPH is still a major killer of mothers
Percentage distribution of causes of maternal death,Bangladesh, 2016
4. Incidence
● 1 death every 4 min!!!!
● Death due to PPH occurs within 2 hours if no
active intervention taken , as compared to APH –
12 hours , obstructed labor - 2 days , infection –
6 days
5.
6. Clinical Definition
Any bleeding from or into the genital tract
following birth of the baby up to the end of
puerperium which adversely affects the general
condition of the patient evidenced by rise in
pulse rate and falling blood pressure is called
"Post Partum Hemorrhage (PPH)”
7. Quantitative definition
● Quantitative definition is arbitrary and related
to amount of blood loss in excess of 500 ml
following birth of the baby(WHO)
● Average amount of blood loss:
⮚ Following vaginal delivery : 500 ml
⮚ Following caesarean section : 1000 ml
⮚Following caesarean hysterectomy : 1500ml
10. Atonic Uterus (80%): Risk factors
⮚ Grand multipara
⮚ Over distended Uterus: multiple pg, hydroamnion, big baby(>4kg)
⮚ Malnutrition & Anemia (<9.0g/dl)
⮚ APH( Both placenta previa & abruptio placenta)
⮚ Prolong labor(>12 hr): poor retraction, amnionitis
⮚ Anesthesia: ether, halothane
⮚ Malformation of Uterus
⮚ Fibroid : Causes imperfect retraction
⮚ Mismanaged Third stage of labor
⮚ Placenta (accreta, percreta)
⮚ Others: obesity(BMI>35), drugs(MgSO4,nifedipine) age(>40y)
11. Traumatic(20%)
1. Laceration of the cervix, vagina, perineum and peri-
urethral tear- mostly in instrumental delivery, complicated
vaginal delivery.
2. Ruptured uterus
3. Extension of the cesarean section incision- Uterine
artery tear.
4. Broad ligament hematoma.
5. Uterine inversion
12. Thrombin(Blood coagulopathy)
Due to diminished procoagulant or increased fibrinolytic activity.
Condition where such disorders occurs:
⮚ Abruptio placenta
⮚ Jaundice in pregnancy
⮚ Thrombocytopenic purpura
⮚ Severe pre eclampsia
⮚ HELLP syndrome
⮚ IUD
13. Clinical Presentation
Symptoms:
PV bleeding with or without visible blood loss within 24 hr following birth of the baby
Signs :
Pallor
Features of shock
Altered level of conciousness
Well contracted uterus ( Tramatic)
Flabby uterus & hard on massaging ( atonic cause)
14. Investigations
Blood:
Blood grouping & Rh typing , Hb%
Coagulation Profile:
BT,CT & PT time
USG :
for any retained bits of placenta (After resuscitation of patient )
15. Immediate management
Shout for help
↓
Monitoring of vital signs
↓
Monitoring urine output (continuous catheterization)
↓
Palpate the uterus & massaging the uterus
↓
Look placenta is expelled out or not
↓
Opening up of IV channel by two large bore cannula(18G)
↓
Blood grouping & Rh typing and Ask for at least 2 unit FHB
↓
Give O2 by oxygen mask 10-15L/min
↓
Infuse 2L normal saline or plasma substitute
↓
16. Continue………
Start 20 unit of oxytocin in 1L normal saline IV @ 60 d/min
Or , single dose Carbitocin 100mcg IV as an alternative to oxytocin
⮚ Inj Ergometrine 0.5mg IM or IV . Maximum dose 1.25mg (contraindicated when BP high)
⮚ Transfuse blood as soon as it is available
17. In Refractory cases
Tab: Misoprostol ( prostaglandin E1) 800mcg per rectally
is to be administered .
Inj tranexamic acid 0.5gm or 1gm given in addition to
oxytocin
Uterine atony due to tocolytic agent → Calcium
gluconate 1g IV slowly should be given to neutrilize the
calcium blocking effect of drugs.
18. In management of PPH due to uterine inertia
we usually give Inj Oxytocin, Inj Ergometrin, Inj
Carbetocin, Inj Trannexamic acid & Tab
Misoprostol 800 to 1000 micro gm per rectally.
Carbetocin is preferred to Oxytocin.
Carbetocin is heat stable. But Oxytocin is heat
sensitive & for this reason most of the time PPH
due to uterine atony can not be controlled by
Oxytocin.
On the other hand there is delayed
absorption of Misoprostol when it is given
19. Recent guideline suggests the following drugs to manage
PPH due to uterine atony :-
● 1.Inj Carbetocin 1 amp slow i/v
● 2. Inj Trannexamic acid 2gm slow i/v
● 3. Tab Misoprostol 800 micro gm S/L.
● 4. Inj Ergometrin or Inj Syntometrin may also be given if necessary
20. Mechanical method
1. Bimanual uterine compression
2. Compression of the Aorta
3. Uterine temponade
4. Intrauterine packing
22. Condom Tamponade
It is successful in atonic PPH.
This can avoid Hysterectomy in 78% cases
Inflate the condom with 250-500ml of running
normal saline
Uterine contraction is maintained by oxytocin
drip for at least 6 hrs after the procedure
The condom catheter kept for 24-48 hrs then
deflate gradually over 10-15 min
Patient kept under triple antibiotic coverage
(Amoxicilline + Gentamicin+ metronidazole)
23. Surgical Interventions
⮚ B-Lynch compression suture and multiple square suture
(success rate 80% )
⮚ Ligation of uterine arteries
⮚ Bilateral internal iliac artery ligation
⮚ Arterial Embolization
⮚ Total or Subtotal abdominal hysterectomy
25. Ligation of uterine artery
Ascending branch of
the uterine artery is
ligated at the lateral
border between upper
and lower uterine
segment. In atonic
hemorrhage, bilateral
ligation is effective in
about 75%
26. Bilateral internal iliac artery ligation
Reduces the distal blood flow. It helps stable
clot formation by reducing the pulse pressure up
to 85%. Due to extensive collateral circulation,
there is no pelvic tissue necrosis. Bilateral
ligation (not division) can avoid hysterectomy in
about 50% of the cases
27. Prevention
1. Regular antenatal care
2. Correction of anemia and malnutrition
3. Identify the risk women and deliver them in a
hospital where emergency obstetric facility
available
4. By doing active management of third stage of
labor( AMTSL)
28. Antenatal care
● Improvement of the health status of the women
● Keep the Hb level >10g/dl
● Screening the high risk patient ( Twin, grand multipara, severe
anemia, H/O PPH,APH)
● Blood grouping & Rh Typing
● Placental Localization by USG
● Women with morbid adherent placenta are high risk of PPH. Such
case should be delivered by senior obstetrician.
29. Intranatal care
● Active management of third stage of labor reduce PPH 60%
● Women delivered by C/S oxytocin 5 IU IV slowly given to
reduce blood loss. Long acting carbitocin is very useful to
prevent PPH
● Observation of uterovaginal canal to find out any trauma
● Examination of placenta and membrane to detect any
missing part
● Observation for two hours after delivery to make sure that
uterus is hard and contracted
30. Management of third stage bleeding
● The principles in the management are :
Toemptytheuterus
Toreplacetheblood
Toensureeffectivehemostasis
31. Steps of third stage management
1. After delivery of the baby ,first
we should exclude twin present
or not . If twin present ,don’t
give oxytocin .
2. After exclude twin pregnancy,
then Inj Oxytocin 10 IU IM is to
given within one minute of
delivery of the baby .
3. The placenta is to be delivered
by CCT & CT
4. Immediate massage the fundus
of uterus until the uterus
contracted . Massaging every 15
min later upto one hour. So, 4
times an hour.
32. PPH bundle Approach
● First approach:
❑ 1. AMTSL
❑ 2. Open IV fluid channel by Green cannula
❑ 3 Oxytocin 20 IU in 1 litter
❑ 4. tranexamic acid ( we give it when pt come within 3 hrs.
after that it will not work)
❑ 5. ORRT ( Obs rapid response team)
● Second approach : (supportive measure) :
❑ Treat tear
❑ Empty bladder
❑ Empty uterus
33. ● Third approach ; ( Refractory PPH intervention)
❑ Bimanual uterine compression
❑ Aortic compression – only for stoppage bleeding , it is
temporary
❑ Ballon tamponade
❑ Anti shock garments
● Referral
● Surgery
34. Secondary PPH
● Bleeding occuring after 24 hours upto the end of puerperium is callled
secondary PPH
Causes :
● Retained bits of cotyledon , membrane & blood clot
● Infection and separation of slough
● Endometritis & Subinvolution of placenta site
● Haemorrhage from C/S wound
● Inversion of uterus , fibroid ,placental polyp
35. Clinical Manifestation
❖ The lochia are heavier then normal and bright red in color.
❖ Lochia is offensive if associated with infection.
❖ Sub involution of the uterus.
❖ Abdominal cramp
❖ Pyrexia and tachycardia.
❖ Open cervical OS
❖ Anemia proportionate to blood loss.
36. Investigations
● a. Blood grouping and cross matching
● b. Full blood count
● c. Coagulation test
● d. Increased C-reactive protein indicate infection
● e. Vaginal swab for aeorobic and anaerobic bacterial growth
● f. Urine for C/S
● g. Blood culture (if maternal temperature is very high)
● h. USG of pelvis for retained placental tissue
37. Management
Supportive therapy:
Blood transfusion if necessary
ergometrine 0.5 mg IM if bleeding uterine origin
Antibiotic
Conservative theraphy :
bed rest and observation for 24hrs if bleeding is mild
38. Active management
❑ - Exploration of uterus is to be done under general anesthesia.
❑ Gentle curettage is done by flushing curette and sent materials for
histological examination.
❑ Ergometrine 0.5mg IM.
❑ Secondary hemorrhage following cesarean section may at times require
laparotomy. The bleeding from uterine wound can be controlled by
haemostatic sutures, may rarely require ligation of the internal iliac artery
or hysterectomy