PPH

OBSTETRIC DRILLS –PPH
INDIA AUG 2016 6-11TH
HYDERABAD,CHENNAI,MUMBAI,KOLKATA,DELHI
&
LUCKNOW
IAN DONALD SCHOOL OF ULTRASOUND
&
LUPIN
6 DAYS 6 CITIES HANDS ON TRAINING

CONDUCTED BY
• ROBIN BURR(AUSTRALIA)
• SULLEN MILLER(USA)
• NARENDRA MALHOTRA
• SHEELA MANE
• JAIDEEP MALHOTRA
• ALKA KRIPLANI
• SADHNA GUPTA
JAYAM KANAN,ASHISH MUKERJEE,VP PAILEY,APARNA
SHARMA,SEEMA ,AMBUJA C.

© Suellen Miller, 2016
OBSTETRIC DRILLS
THE PPH DRILL

PPH Drill
Jaideep Malhotra
Narendra Malhotra
Neharika Malhotra
RAINBOW HOSPITALS
www.malhotrahospitals.com
www.rainbowhospitals.org

Worldwide issue
Over 300,000 women and 2.7 million newborn babies die
each year in pregnancy and childbirth or soon afterwards,
the majority of them in Africa and South Asia.
Every minute of every day, somewhere in the world a woman
dies from complications related to pregnancy or childbirth.
99% of maternal deaths occur in the developing world
www.womenandchildrenfirst.org.uk/

Postpartum haemorrhage 1,500 ml or more - all women who give birth vaginally
https://women.wcha.asn.au/

MDG - GOAL 5: IMPROVE MATERNAL HEALTH
- Maternal mortality ratio (per 100,000 live births)
Initial
Value
Last
Value
2015
Target
Achieving
target in...
560.0 190.0 140.0 2021

Achieving Millennium Development Goal 5: is India serious?
Dileep Mavalankar, Kranti Vora, M Prakasamma
India - largest number of births per year (27 million) in the world.
Maternal mortality of about 300–500 per 100 000 births, about 75
000 to 150 000 maternal deaths occur every year in India.
• Absence of focus on emergency obstetric care
• Missing midwives
• Lack of management capacity in the health system
• No political will
• Absence of comprehensive maternal care services
Bulletin of the World Health Organization>Past issues>Volume 86: 2008>Volume 86, Number
4, April 2008, 241-320

MMR India over time
Year MMR
1990 556
1995 471
2000 374
2005 280
2010 215
2015 174
Source: WHO,UNICEF
, UNFP
A,W
orldBankGroupandUNPD
(MMEIG)- November 2015

Definitions
Primary PPH
> 500 ml (spontaneous delivery)
> 1000 ml (caesarean section)
Severe haemorrhage:
blood loss > 150 ml/min (within 20 min causing loss of more
than 50% of blood volume)
sudden blood loss > 1500-2000 ml (uterine atony; loss of 25-
35% of blood volume).

Causes of PPH: the 4 T’s
Tone: uterine atony, distended bladder.
Trauma: uterine, cervical, or vaginal injury.
Tissue: retained placenta or clots.
Thrombin: pre-existing or acquired coagulopathy.

Antenatal risk factors
• Polyhydramnios
• Multiple pregnancy
• Fibroids
• Past PPH
• Previous retained placenta
• Previous Caesarean Section/ uterine
surgery
• Placenta praevia/percreta/ increta
• APH
• High parity
• Maternal Age
• Obesity
• Drugs e.g. Nifedipine/MgSO4/
salbutamol
• Hypertensive disorders
• Pre-existing coagulation disorder
e.g. Von Willebrand’s
• Therapeutic anticoagulation
• Anaemia

Intrapartum risks
• Fetal demise in utero
• Abruption
• Induction/augmentation of
labour
• Prolonged labour
• Pyrexia
• Prolonged ruptured
membranes
• Instrumental delivery
• Episiotomy
• Retained
placenta/membranes
• Physiological third stage
• Drugs e.g. inhaled
anaesthetic agents
• Therapeutic anticoagulation/
DIC

Third stage of Labour
PPH ACTIVE EXPECTANT
>500 mls 5% 13%
>1000 mls 1% 3%

Active vs Expectant Management
Outcome Control Rate, % Relative Risk 95% CI* NNT † 95% CI
PPH of 500 mL 14 0.38 0.32-0.46 12 10-14
PPH of 1000 mL 2.6 0.33 0.21-0.51 55 42-91
Hemoglobin < 9 g/dL 6.1 0.4 0.29-0.55 27 20-40
Blood transfusion 2.3 0.44 0.22-0.53 67 48-111
Therapeutic 17 0.2 0.17-0.25 7 6-8
uterotonics
*CI: Confidence interval
† NNT: Number needed to treat
Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of
labour. Cochrane Database Syst Rev. 2000. CD000007.

AMTSL @ WH
23.0%
24.0%
25.0%
26.0%
27.0%
28.0%
29.0%
30.0%
31.0%
1 2 3 4
PPH Rate
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
1 2 3 4
Major PPH Rate

The GOLDEN HOUR
• The first 60 minutes after the start of the PPH
• The greater the delay in starting resuscitation, the
lower the percentage of survivors
• However may not be true in trauma & too late in
PPH!
• FIRST 20 minutes?

PPH Management
ASSESS
• Observations
• Cause of bleeding
• Investigations
ARREST
• Fundal massage
• Drugs
REPLACE
• IV Fluids

Confidential enquiries (UK)
TOO LITTLE
 Uterotonics
 Fluid
 Blood
 Blood products
TOO LATE
 Recognition
 Reaction
 Intervention

Drugs
• Oxytocin - 10U IM/IV
• Ergometrine - 500 mcg IV/IM
• Prostaglandins
• Carboprost – 250 mcg IM x8
• Misoprostol – 600 mg PO / 800 mg PR
• Carbetocin

Uterotonic Drugs
Drug Dosage Action Side Effects Caution
Oxytocin 10U IM/IV
Onset: 2-3 mins
Lasts: 10-15 mins
Minimal None
Ergometrine 500mcg IV/IM
Onset: 2-7 mins
Lasts: 2-4 hours
Nausea, vomiting,
headache,
hypertension
Hypertension
Carboprost 250mcg IM
Onset: 1-2 mins
Lasts: 15-20 mins
Vomiting,
diarrhoea,
bronchospasm
Brittle asthma
Misoprostol
800mcg SL/PR
600mcg PO
Onset: 3-5 mins
Peak: 20-30 mins
Lasts: <75 mins
Shivering, rise in
temperature
None

Misoprostol FIGO
• A single dose of misoprostol 600μg
orally for prevention
• One dose of misoprostol 800 μg
sublingually for treatment
• Administered immediately after
delivery of the newborn
• Contraindications - History of
allergy to misoprostol or other
prostaglandin
• FIGO 2012

Fluids
• Colloids vs Crystalloids
• Volume
• Warm
• Speed
• IV lines - Two large bore IV access –
Grey/Green (No. 16 or 18)

IV Access
Gauge Color Flow rate
16 Grey 180 mL/min
18 Green 80 mL/min
20 Pink 54 mL/min
22 Blue 31 mL/min

Other
• Airway, breathing, circulation
• Oxygen by face mask – 6 to 8L per minute
• Fundal massage
• O negative blood
• Cross matched blood
• Massive Transfusion Protocol

Blood loss Estimation
Dr Robin Burr

The challenges
• Visual estimation
• Measuring aids
• Clinical impact
• Shock
• MEOWS

Visual Estimation of Blood Loss
• Caregivers consistently underestimate visible
blood loss by as much as 50%.
Razvi K, Chua S, Arulkumaran S, Ratnam SS. A comparison between visual estimation and
laboratory determination of blood loss during the third stage of labor. Aust N Z J Obstet
Gynaecol 1996;36:152–4
• Can be improved with training using visual aids
Bose P,Regan F,Paterson-Brown S. Improving the accuracy of estimated blood loss at
obstetric haemorrhage using clinical reconstructions. BJOG. 2006 Aug;113(8):919-24.

Blood loss – quick quiz 1
• 0 - 500 mls?
• 500 - 1000 mls?
• 1000 - 1500 mls?
• 1500 - 2000 mls?
• 2000 - 2500 mls?
• >2500 mls?

• 0 - 500 mls?
• 500 - 1000 mls?
• 1000 - 1500 mls?
• 1500 - 2000 mls?
• 2000 - 2500 mls?
• >2500 mls?

BRASSS-V Drape™
• Placed under woman
• Two ties around waist
• Blood drains into
calibrated pouch
Kodkany BS, Derman RJ, Goudar SS, et al. Initiating a
novel therapy in preventing postpartum hemorrhage in
rural India: a joint collaboration between the United
States and India. Int J Fertil Women Med 2004;49:91–6

Kelly’s Pad
• The patient sits on this
device
• The pad funnels the
blood into a collection
container which has a
marked line at 500 mL
• This device is washable
and can be sterilized

Blood Mat
•20” x 20”
•= 500mls
photo: Pathfinder staff/Bangladesh

Local materials
Weighed gauze, swabs, pads
Kanga (100x155 cm) x2 = 500mls

PPH and shock
Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock
500-1000 mL (10-15%) Normal
Palpitations, tachycardia,
dizziness
Compensated
1000-1500 mL (15-25%) Slight fall (80-100 mm Hg)
Weakness, tachycardia,
sweating
Mild
1500-2000 mL (25-35%) Moderate fall (70-80 mm Hg)
Restlessness, pallor,
oliguria
Moderate
2000-3000 mL (35-50%) Marked fall (50-70 mm Hg)
Collapse, air hunger,
anuria
Severe

Monitoring: MEWS
• Observation of vital signs are an integral part of care
• There is a potential for any woman to be at risk of
physiological deterioration and this cannot always be
predicted.
• There is poor recognition of deterioration in condition.
• Regular recording and documentation of vital signs will aid
recognition of any change in a woman’s condition
• The use of EWS chart prompts early referral to an appropriate
practitioner, who can undertake a full review, order
appropriate investigations, resuscitate and treat as required

Monitor
Identify
Trigger
Alert
Evaluate
Diagnose
Respond
MATERNAL EARLY
WARNING SYSTEM

MEOWS Chart
• All women whose clinical condition requires close
observation; admitted early pregnancy, antenatal or
postnatal
• All post operative cases – in recovery and following
transfer from theatre
• Any woman giving cause for concern (medical or
obstetric causes)
• During/Following APH/PPH/Eclampsia
• Suspected infection e.g. Prolonged SROM
• High-risk women in delivery suite (not in labour)

The Value of MEWS charts
• 676 consecutive obstetric admissions
• 200 patient (30%) triggered and 86 patients (13%) had morbidity
• haemorrhage (43%)
• hypertensive disease of pregnancy (31%)
• suspected infection (20%)
• 89% sensitive (95% CI 81–95%)
• 79% speciﬁc (95% CI 76–82%)
• positive predictive value 39% (95% CI 32–46%)
• negative predictive value of 98% (95% CI 96–99%)

Obstetric HDU/ICU
Dr Robin Burr

Rationale for an Obstetric HDU
• Modified early warning scoring systems improve the
detection of life threatening illness.
• It is the subsequent management that will alter the
outcome.

Other drivers for change
CEMACH 1988 - 90
“properly equipped, staffed and supervised high dependency
area in every consultant obstetric unit”
SAFER CHILDBIRTH - 2007
“all obstetric units should be able to provide some high
dependency care”
1 in 100 deliveries

Advantages of an Obstetric HDU
• Concurrent availability of obstetric and critical care
management
• Awareness of physiology and pathology of the maternity
patient
• Fetal monitoring in antenatal patients
• Avoiding hazards of transfer
• Keeping mum and baby together
• Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDU
• Skill levels of Midwives/Obstetric Nurses
• Skill levels of Junior doctors
• Anaesthetic support
• Location
• Equipment
• ICU outreach

Levels of Care
• Level 0 - normal ward care
• Level 1 - needing more observation
Critical Care:
• Level 2 - support of one organ
• Basic respiratory &/or cardiovascular support
• Level 3 - advanced support
• Advanced respiratory support alone
• Support of 2 or more organs
Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deterioration
Low-score group: (EWS =3)
o Increased frequency of observations and the midwife in charge alerted.
Medium-score group: (EWS =4, 5)
o Urgent call to team with primary medical responsibility for the patient.
o Simultaneous call to personnel with core competences for acute illness.
High-score group: (EWS ≥ 6)
o Emergency call to team with critical care competences and maternity team.
o There should be an immediate response.

Admissions to HDU
• Obstetric Indications
– Eclampsia
– Sepsis
– Severe pre-eclampsia
– Severe asthma
– Major haemorrhage
– Diabetic ketoacidosis
– Thromboembolism
– HELLP syndrome
– Puerperal sepsis
• Non-obstetric indications
– Transfer from ICU
– Other surgical procedures or complications
– related to surgical condition
– Pneumonia/ respiratory embarrassment
– Hypertension
– Renal impairment
– Thyrotoxicosis
– Cardiac or neurological co-morbidity
– Morbid obesity (BMI >40kg/m2) with
comorbidities.

Minimum equipment requirements
o Piped oxygen
o Suction equipment
o Resuscitation equipment including ready access to defibrillator
o Pulse oximeter
o Non-invasive blood pressure monitor
o ECG waveform monitor
o Calf compression device
o Invasive haemodynamic monitoring
o Level 1 fluid infuser

Transfers out of HDU
• Failure of more than one organ system
• Disease requiring the expertise of specialist medical teams e.g.
• Renal failure, other than the impairment associated with preeclampsia
• Hepatic failure
• Respiratory disease especially that requiring ventilatory support
• Cardiac disease, pre-existing or of recent onset
• Neurological conditions
• Endocrine disease including diabetes mellitus
• Non-obstetric surgical problems

Transfer of care
• Guidelines
• Clear plan
• Timing of transfer
• Continuity of care
• Structured formal handovers
• summary of critical care stay
• a monitoring plan detailing the frequency of observations
• An plan for ongoing treatment
• physical and rehabilitation needs
• psychological and emotional needs
• specific communication or language needs

Discharges to ward
• Patient haemodynamically stable, no further continuous
intravenous medication or frequent blood tests required
• No invasive monitoring required
• No active bleeding
• No supplementary oxygen required
• Patient mobilized

ISBAR tool
Identification: identify yourself and your role to the person you are
communicating with in the communication.
Situation: describe the specific situation about a particular patient,
including name, consultant, patient location, vital signs, resuscitation
status and any specific concerns.
Background: communicate the patient’s background, including date of
admission, diagnosis, current medications, allergies, laboratory results,
progress during the admission and other relevant information.
Assessment: this involves critical assessment of the situation, clinical
impression and detailed expression of concerns.
Recommendation: this includes the management plan, suggestions for
care, detail of investigation requests and expected time frame.

UK Obstetric HDU
• Admissions rose from 2.67% to 5.01%
• Massive obstetric haemorrhage is now the most common
reason for admission.
• Invasive monitoring in 30%
• Two-thirds of neonates (66.3%) stayed with their critically ill
mothers in the high dependency unit.
• Transfer to the intensive care unit was needed in 1.4 per
1000 deliveries conducted.

Indian Obstetric HDU
• Admission rate - 9.4%
• Severe P.I.H with complications - 26%,
• Placenta praevia APH - 3.14%,
• Abruptio placenta - 5.7%,
• P.P.H - 14%,
• P.R.O.M with sepsis - 8%
• Medical complications in pregnancy - 24.2%
• HDU mortality rate was 3.7% (69.2% were preventable deaths)

Transfer of Patient
PPH Module 2014

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)
PPH Module 2014

Prerequisites for Transfer
Informed consent
Anti shock Garment (NASG)
Check availability of bed 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 PPH Module 2014

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risk factors
Intranatal events:
Delivery notes: Vaginal/Instrumental/C 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
PPH Module 2014

O
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ta
ra
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ns
xf
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gren on flow
Two IV lines (#16/18) with fluid on flow
Nurse or Doctor & Patient’s able attendant
to accompany
PPH Module 2014

NASG: Updates on Clinical Trial Results,
Implementation Trials, Cost Effectiveness, and
Global Guidelines
Professor Suellen Miller,
University of California, San Francisco
Dept. Obs/Gyn & Reproductive Sciences
Director, Safe Motherhood Program

Used in Over 33 Countries Globally

Where in India?
Pathfinder, Raksha Project, 2007-2012
Tamil Nadu, Rajasthan, Bijar, Orrissa, Maharashtra,Assam, Agra
Pathfinder and World Health Partners in UP
Dr. Narendar Malhotra, Rainbow Hospitals
Dr. Sheela Mane, throughout India

Clinical Trials: Tertiary Level
5 peer-reviewed studies: 4 pre-post design, 1 (India) contemporaneous use
3,651 women: Severe OH (>1000 mL) with clinical sxs of shock
1614 (45.3%), standard care, 1947, 54.7% standard care + NASG
Sub-analysis of Severe Shock
(1227 MAP < 60 mm HG, 594, std care; 633, 51.6% std care + NASG)
Meta-analytic Techniques to pool all data

Outcomes: NASG Tertiary Level
•LifeWrap significantly reduced mortality 48% RR: 0.52 (95% CI 0.36-0.77)
Pileggi-Castro C; Nogueira-Pileggi V; Tuncalp O; Oladapo OT; Vogel JP; Souza JP.
Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage
: a systematic review. (2015) Reproductive Health; 12:28.

Clinical Trials: Primary Level
Zambia and Zimbabwe, 2007-2012
880 women transported from PHCs, midwifery directed, no blood/surgery
Clinics randomized to standard care vs. standard care plus NASG before transport for hypovolemic
shock
38 clinics, 5 tertiary facilities
OUTCOMES: Mortality and Time to Recovery of Shock
Similar in magnitude of effect and trend of the Tertiary Facilities
Non-pneumatic Anti-Shock Garment (NASG), a First-Aid Device to Decrease Maternal Mortality from Obstetric
Hemorrhage: A Cluster Randomized Trial. Miller, S; Bergel, EF; El Ayadi, A; Gibbons, L; Butrick, E; Magwali, T;
Mkumba, G; Kaseba, C; My Huong, NT; Geissler, JD; Merialdi, M.(2013) PLOS ONE; 8(10): e76477.

Pragmatic Trial/Implementation Science: 334 PHCs
Rural Tanzania
Baseline: all hemorrhage >500 mL
Endline: Severe hemorrhage only, >1000 mL or signs of hypovolemia
*P < 0.01

Cost-Effective Analyses
• Comparison of CEA at Tertiary Level, 1442 women
• Egypt: Cost BENEFICIAL, save health system $10,000/1000 women with
shock
• Nigeria, Zambia, Zimbabwe: Extremely COST EFFECTIVE
Cost-effectiveness of the non-pneumatic anti-shock garment (NASG): evidence from a cluster randomized controlled trial in Zambia and Zimbabwe. Downing J; El
Ayadi A; Miller S; Butrick E; Mkumba G; Magwali T; Kaseba-Sata C; Kahn JG. (2015) BMC; 15:37.
Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage: A Cost-Effectiveness Analysis in Egypt and Nigeria. Sutherland,
T; Downing, J; Miller, S; Bishai, DM; Butrick, E; Fathalla, MF; Mourad-Youssif, M; Ojengbede, O; Nsima, D; Kahn, JG. (2013) PLOS ONE; 8(4):e62282.

Non-Pneumatic Anti Shock Garment
(NASG)
PPH Module 2014

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
PPH Module 2014

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
PPH Module 2014

How does NASG work?
In shock, the brain, heart and lungs are deprived of oxygen
because blood accumulates in the lower abdomen and legs
in addition to blood loss from the vagina during obstetric
hemorrhage
The NASG applies circumferential counter pressure which
reverses shock
• By returning blood to the vital organs
• Decreasing blood flow in the compressed areas
• Decreasing blood loss
PPH Module 2014

NASG’s Unique Role in Obstetric
Hemorrhage and Hypovolemic Shock
Used with hemorrhage therapies, uterotonics, massage, vaginal
procedures, even surgeries
Does not compete with other approaches: Not an either or situation, first-
aid device that buys time
A technology that can be used when patient with uterine atony does not
respond to uterotonics
AND
Effective for ALL obstetric hemorrhage: rupture, lacerations, ectopic
Only technology that reverses shock, until blood transfusions
Can be used with balloon tamponade to reverse shock

About NASG
NASG is light weight (1500 G)
Compression suit made of Neoprene
Five segments enclosing ankle, thigh, calves, 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
PPH Module 2014

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
PPH Module 2014

NASG (Life wrap)
PPH Module 2014

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
PPH Module 2014

Step
A
3p
: plying NASG
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
PPH Module 2014

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
PPH Module 2014

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
PPH Module 2014

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
PPH Module 2014

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
PPH Module 2014

Special situations
Obese women
Short stature
Need for defecation
Replacing soiled NASG
PPH Module 2014

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
PPH Module 2014

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
PPH Module 2014

Do not remove NASG before all vital signs are
restored
Early removal of NASG can be dangerous or even
fatal
PPH Module 2014

If B
CP
af
ua
tl
l
is
onb
y20 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 & arrest
PPH Module 2014

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
PPH Module 2014

Relative contraindications
Cardiac failure
Pre existing Mitral stenosis / Pulmonary edema
Advanced pregnancy with live fetus (APH)
Abdominal evisceration
Open pelvic fracture
PPH Module 2014

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
PPH Module 2014

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
PPH Module 2014

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
PPH Module 2014

Added to
WHO
Guidelines
for PPH in
2012

FIGO Guidelines
1. Non-pneumatic anti-shock garment to stabilize women with hypovolemic
shock secondary to obstetric hemorrhage☆ FIGO Safe Motherhood and
Newborn Health Committee (2014)
http://dx.doi.org/10.1016/j.ijgo.2014.10.014
2. FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage
in low-resource settings, FIGO Safe Motherhood and Newborn Health
(SMNH) Committee, International Journal of Gynecology and Obstetrics 117
(2012) 108–118, doi:10.1016/j.ijgo.2012.03.001

Partnership for Distribution in LMIC/EMEC/UN
•United Nations Commission on Life Saving Commodities for Women and
Children’s Health
• CHAI
• UCSF/Safe Motherhood Program
• BlueFuzion: UNGM (United Nations Global Marketplace)
• Higher Quality, Lower Price, Increased Reusability
• $0.30 /use
• $42.00/garment and Wash/Reuse Cycles ~ 140 times

Hemorrhage Etiologies: UCSF
29%
11%
16%
12%
4%
7%
2%
19%
Atony
Lacerations
Retained
Placenta
Ruptured Ut
Ectopic
Other
Abortion
N = 4,191

Safety
> 10,000 documented cases
NO REPORTS of any safety issues
NO INCREASE of side effects minor or major due to use of NASG
Used now routinely in Africa/Asia/
South America
Large-Scale, Pragmatic
“operations research”
in Tanzania, East Timor, and others

Conclusions
•Statistically significant decreases in time to return to normal Shock Index in quasi-experimental and
RCTs
•At the TERTIARY LEVEL~ 58% significant reduction in MORTALITY across several quasi-experimental
studies
•Randomized Trial at PHC/Earlier Application: 64% reduction in mortality, ns
•Cost Effective or Cost-Beneficial
•On WHO and FIGO GUIDELINES, UN Marketplace Vendor/NASG, AICOG:
•In 10,000 cases carefully documented, there were no adverse events related to NASG use: SAFE
•Now in use in over 33 countries globally

Innovations in Triage and Treatment of Obstetric
PRESENTED BY
PROF. NARENDRA MALHOTRA
MD,FICOG,FICMCH,FICS,FRCOG
Professor Suellen Miller
University of California, San Francisco

. . . the most common and severe type of obstetric
enigma to the present day
haemmorrhage, is still an
obstetrician
as it is sudden,
often unpredicted,
assessed subjectively
and can be catastrophic.
The clinical picture changes so rapidly that unless timely
action is taken maternal death occurs within a short period.
POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors
• Pre-eclampsia
• Nulliparity
• Multiple gestation
• Previous post-partum haemorrhage
• Previous caesarean section
• 60% have no risk factors
• Prolonged 1st & 2nd stage
• Prolonged active third stage (>30 min)
• Arrest of descent
• Episiotomy
• Lacerations: cervical, vaginal, perineal
• Assisted birth
• Use of oxytocics
Ante-natal
Intra-partum

Be Ready for it all the time l
Drill is a practice and
anticipation
& task allotment to tackle emergencies
Fire drill/earth quake drill etc etc
PPH drill should be taught , practised and rehearsed in obstetric set up so that every one is prepared for the
emergency and know what to do

Emergency Trolley
Endotracheal tube
Laryngoscope
Essential drugs
Crystalloids, giving sets, haemacel
Emergency protocols
GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)
Crystalloids

TRIAGE: Early Identification of Hemorrhage
First
De l ay:
Recognizing
C o m p lications
S e cond
Delay:
Deciding to
S e e k Care
Third Delay:
A ccessing
Tran sp ort
Fourth
Delay:
Receiving Care
at Facility
TRIAGE: Early Identification of Hemorrhage
TREATMENTS: Stop Bleeding, Stabilize for Transport

Low Tech Blood Loss Assessment
350 mL
500 mL

GOES UNDER THE
BUTTOCK OF MOTHER
RINGS-A string from each go around the buttock
to be tied together suprapubically for double fixing
REUSABLE TYPE BLOOD COLLECTOR PAN
(DEBDAS)

Vital Signs as Predictors
Blood loss estimate not a reliable predictor of outcome
Pulse and Blood Pressure measurements are often difficult to obtain accurately
PP Circulatory changes VS changes may be detected too late
More sensitive predictor of adverse outcomes and management tool needed
Shock Index: Pulse/Systolic BP

CRADLE/Microlife
Traffic Light Vital Sign Alert
(VSA)
Developed by King’s College London,
Prof. Andrew Sheenan, Hannah Nathan,
Natasha Helzegrave

Suitable for Use in Low Resource Setting
Parati et al 2005
• Accurate
• Affordable - $19 per unit
• Easy to use
• Robust
• Low power requirements
• A lifetime use of >20,000 extreme inflations
• Can be used with a stethoscope as an alternative to a mercury column
• Hypertensive Disorders & Hypertension/Shock

Shock Index Thresholds
HR/SBP
SI ≥ 1.7
SI 0.9 – 1.69
SI <0.9
Nathan H.L., El Ayadi A.M., Hezelgrave N.L., Seed P., Butrick E., Miller S., et al. (2015) Shock index: an effective predictor
of outcome in postpartum haemorrhage? BJOG 122(2),268-75.

KCL CRADLE Research
• Prospective clinical evaluation of device and traffic light system ongoing in South Africa
• Larger Prospective Stepped Wedge Randomised Trial
Collaborating with KLE University, India
Evaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-
income country sites

Phone Pulse Oximeter
Pulse Oximeter noninvasive, measures oxygen saturation by shining
infrared light through the finger (measures redness of blood), low
oxygen saturation in hypovolemic shock
The Phone Oximeter is a smartphone application which receives data
in real time from a connected pulse oximeter
Minimal Training, <$50.00/unit
Developed at University of British Columbia, part of Global PRE-EMPT

Triage: TRIGGER ACTION
Recognition of Hemorrhage/Shock
INITIATE ACTION:
Stop Bleeding
Medical Treatment:
• Uterotonics/Carboprost (0.25 mg IM)
• TXA IV administration
• Pressure: Massage, Bimanual Compression, Aortic Compression
Treat Shock
IV fluids
Warmth, Trendelenberg
Referral/transport
Definitive Therapies
• Blood
• Surgery © Suellen Miller, 2016

LifeWrap/NASG
Unique first aid device, reverses shock and decreases blood loss mitigates
delays in transport and at facilities
Tested on 10,000 women
5 studies: Systematic Review published in BMC RH showed ss 48% decrease
in mortality, ss 69% reduction in SMO
WHO, FIGO, AICOG PPH Guidelines
United Nations Commission on Life Saving Commodities for Women and
Children’s Health, CHAI,UCSF/Safe Motherhood Program, and Blue Fuzion
$0.30 /use--$42.00 and Wash Cycles > 100

Laerdal Compression Belt
St. George’s Hospital and University of London
Currently being tested in Sri Lanka
Uterine/pelvic vessel compression with an inflatable cuff on the uterus and an
inflatable cuff on a suprapublic wedge
VS Talaulikaret. al, IJGO, 2015, A pilot study of the impact of a novel compression belt on pelvic blood flow in
healthy postpartum women © Suellen Miller, 2016

University of Liverpool: The Butterfly
Prof. Andrew Weeks

Improving on Current Treatments

ESM-UBTTM
Innovative, ultra low cost (less than USD $3 per UBT
device) package:
Device
Targeted training
Checklists
• 235 women severe hemorrhage; arrested in 233 of 235
• 98% of women with severe uncontrolled hemorrhage
survived
• Survival fell to 83% if an improvised UBT device was used
instead of one that was prepackaged and readily available
Mass General Global Health /Thomas Burke
Burke TF et al. A postpartum hemorrhage package w
i
t
h
©c
o
n
Sd
uo
em
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eB
nT
:
MA
ip
llr
eo
s
r
,p
e
2c
0t
i
1v
e
6
multi-center case series in Kenya, Sierra Leone, Senegal, and Nepal. BJOG. July 21, 2015

The UBT device arrests
hemorrhage directly at the
site of disrupted vessels.

PATH/SINAPI UBT KIT
PATH is working closely with SINAPI biomedical in
South Africa.
The SINAPI Balloon meets a critical need in low-
resource settings for an affordable, easy to use fully
assembled UBT.
When inserted into the uterus and filled with water,
the UBT exerts pressure that stops the bleeding
within 5 to 15 minutes
Gravity-fed filling mechanism makes it easier &
faster
Clinical trials to take place in 2016 to confirm safety.
PATH’s low-cost UBT solution
is promising for expanding
access to life-saving PPH
treatments
SINAPI
biomedical/Christiaan
van
Aardt.

Synergy of TXA/Thrombin/UBT
In porcine and murine testing
gas generating microparticles
of CaCO3 with TXA and thrombin
self propel (through lateral
propulsion, buoyant rise and
convection) to the bleeding site
and function hemostatically to
halt hemorrhage for traumatic
and intraoperative bleeding
Model Concept would be to
apply TXA/Thrombin/CaCO3
to a UBT both to enhance drug
delivery and apply physical
Tamponade
Baylis et. al, Self-propelled particles that transport cargo through flowing blood and halt hemorrhage
Sci Adv. 2015. © Suellen Miller, 2016

The InPress
1. Seal created in birth canal
2. Light vacuum force uterine
cavity
3. Uterus contracts and vessels
constricted
• Immediately assess the efficacy of the treatment
• Allows physician to accurately measure blood loss
Clinical Experience: 10 patients in Jakarta, IN
• Hemorrhaging controlled <2 minutes
• Device removal unremarkable, no recurrence of bleeding
• CE Mark Application and Pre-IDE Submission to FDA

The InPress: How it Works

Now, about that drone…….

1 Health facility orders blood via
mobile Drone can carry up to 1.0 kg in
75 km radius
3
4 Drone drops package at health
facility in 15-45 min
Zipline: Rapid, On-demand, Aerial Delivery of
Blood/Uterotonics/Emergency Supplies
2 dispatches a drone with
package
Ifakara Health Institute Tanzania & Z©
ipSluineell
eInnM
c.ilPleirl,
o2
t0
S1
6LABGrant

Zipline Delivers Blood/Medications/LifeWraps in
Rwanda & Tanzania

Conclusions: Innovations Now and On the Horizon
Triage
Cradle/Microlife Traffic Light Vital Signs Device (SI): Early Warning Device can be used at any level of the
health care system
Phone Pulse Oximeter (O2 Saturation)
Medications: Carboprost, TXA
NASG to decrease bleeding, reverse shock, stabilize women until definitive care
Abdominal Compression Belt and Butterfly Device
Variety of low cost intrauterine tamponade devices
DIY condom
ESM-UBT Kit
PATH/SINAPI UBT
UBC: UBT + CaCO3/TXA/Thrombin model
Drones and solar power (blood banks) may bring blood transfusion capacity/drugs/LifeWraps
closer to where women bleed© Suellen Miller, 2016

Balloon Tamponade
•A balloon (inflated with saline/water) exerts pressure to stop bleeding from within the
uterus in 5-15 mins.
•Is very effective (≥85%) when uterotonics fail. Can prevent need for laparotomy and
hysterectomy. (Reported success rates for the control and
management of PPH with uterine tamponade are quite high and
range between 70-100%.)
•Easy to use
•Can effectively be used in low resource settings

D
E
B
D
IA
NSD
B
L
I
O
A
O
D
N
E
S
I
N
T
I
M
N
A
T
O
I
O
V
N
AS
Y
TS
T
I
E
O
M
N
S
CONDOM BALLON TAMPONADE
UTERINE PACKING

TAMPONADE TEST
Therapeutic & Prognostic
For severe PPH
Stomach balloon
Oesophageal
balloon
Condous G, Arulkumaran S et.al.
Obstetrics & Gynecology. 2003

182
Balloon Tamponade
Atonic PPH unresponsive to uterotonic drugs
Condom tamponade

WHO RECOMMENDATIONS
1- Uterotonics Play a central role in treatment
2-uterine massage is advised
3- initial crystalloids recommended
4--use of Tx in refractory trauma bleeding
5-intrauterine balloon in refractory bleeding and when uterotonic not available
6-Bimanual uterine compression
7 external aortic compression
use of non pneumaticanti shock garments as temporizing measures
8 still not controlled then Uterine aa embolization should b considered
9 Despite all if not controlled then surgical intervention should b done without delay

Thank You
Acknowledgements:
Elizabeth Abu Haider: PATH/SINAPI UBT
Mark Ansermino & Beth Payne: UBC, Phone Oximeter
Christian Kastrup: UBC, UBT/CaCO3/TXA/Thrombin
Jessie Becker, Amy Degenkolb, Jan Segnitz,
Nathan Bair: Inpress Device
Vikram S Talaulikar & Sabaratnam Arulkumaran:
St. George’s Hospital, Compression Belt
Andrew Weeks: Liverpool University, Butterfly
Hannah Nathan, Andrew Sheenan: KCL, CRADLE/Microlife VSA
Thomas Burke: U of Mass, ESM-UBT
Zac Mtema & Godfrey Mbaruku: IHI/Zipline Tanzania
Nick Hu: Zipline California, USA

Thank You

MILLENIUM DEVELOPMENT
GOALS
Are now
SUSTAINABLE
DEVELOPMENTAL GOALS
THANK YOU

PPH

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