ppp-pph

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Postpartum Hemorrhage

Every minute…., Everyday….., some where in

the world …….and most often in a

Developing country,

….a woman dies from complications of pregnancy.

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Magnitude of Magnitude of the problemthe problem

WHOWHO

25.7% Of maternal 25.7% Of maternal deaths in world deaths in world occur in India.occur in India.

MMR 353/lakh live MMR 353/lakh live births .(2004-2005)births .(2004-2005)

Hemorrhage is the Hemorrhage is the leading cause.leading cause.

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2

MMR IN INDIA

25.7India

Rest of the world


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POSTPARTUM POSTPARTUM HAEMORRAGEHAEMORRAGE

Incidence of PPH About 5% of all

deliveries. 60% of all 60% of all

maternal maternal death occur post death occur post

partum.partum.

45% 0f this 45% 0f this occur in 1occur in 1stst 24 24 hrs of delivery.hrs of delivery.

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2

1

2

60%

45%

postpartum

<24hrs

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3 3 DsDs causing thecausing the 4th 4th DD(eath)(eath)

1. D1. Delayelay in recognizing & seeking in recognizing & seeking help.help.

2.2. DDelay in transport & reaching elay in transport & reaching medical facility.medical facility.

33.. D Delay in receiving an adequate & elay in receiving an adequate & comprehensive care upon arrivalcomprehensive care upon arrival


How to diagnose

When to shift?

What & how to give early & appropriate treatment ?

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Anticipate PPH.

Identify PPH / Recognize PPH.

Manage PPH efficiently without

delay.

Prevent maternal death.

Postpartum Hemorrhage OBJECTIVES

PRACTICAL TEACHING & STRUCTURED APPROACH

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Skilled Skilled attendants, attendants, only 42.6 % only 42.6 %

R2 = 0.74

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0 10 20 30 40 50 60 70 80 90 100

Y Log. (Y)

% skilled attendant at delivery

Mat

erna

l dea

ths

per

1000

000

live

birt

hs

INDIAINDIA


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AIM OF THE MODULE

To create preparedness & skill to tackle PPH .

To Ensure correct technique and correct sequence of events in response to PPH.

To create confidence in tackling PPH.

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Postpartum HemorrhageAssess risk Assess risk

factorsfactorsAnte partumAnte partum IntrapartumIntrapartum Post PartumPost Partum

APH/ APH/ Previous Previous PPH / MRPPPH / MRP

Operative Operative delivery,delivery,

ManipulationManipulationss

Genital tract Genital tract injuryinjury

Over Over distended distended uterusuterus

Prolonged Prolonged laborlabor

Retained Retained placentaplacenta

Adherent Adherent placentaplacenta

InfectionInfection Uterine Uterine inversioninversion

Congenital or Acquired Congenital or Acquired CoagulopathyCoagulopathy

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Every woman in labor is at risk of PPH.

2/3 of those with PPH –have no identifiable risk factors.

Active management of third stage of labor should be practiced on ALL women in labor.

All post partum women must be closely monitored for PPH.

Postpartum Hemorrhage REMEMBER

Be prepared in all labors

It prevents 60% of atonic PPH

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ACTIVE MANAGEMENT OF LABOUR

OXYTOCIN<1 min of delivery of baby,

5 units IV bolus/10 units IM /10 units / 500ml NS ( 30 – 40 drops / min. Level I evidence

Controlled cord traction with Counter traction during uterine

contraction

PREVENTIO

N

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Traditional Definition of PPH Blood loss of >500ml following

child birth.Functional Definition Blood loss of <500ml can be fatal in

anemic and in those with contracted intravascular volume as in PIH.

Postpartum Hemorrhage DIAGNOSIS

REMEMBER Blood loss is consistently underestimated

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Even healthy, non anemic women

can have catastrophic blood loss.

Continuous slow bleeding/sudden bleeding

is an emergency

Intervene early and aggressively.

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General Management

Shout for help.Shout for help. Rapid evaluation of vitals.Rapid evaluation of vitals. Oxygen by mask.Oxygen by mask. Uterine massage.Uterine massage. Oxytocin 10 U IM.Oxytocin 10 U IM. Site 2 large bore (16G-gray color) IV cannula, Site 2 large bore (16G-gray color) IV cannula,

Infuse IV fluid – NS / RL- run it fast.Infuse IV fluid – NS / RL- run it fast. Catheterize bladder.Catheterize bladder. Check the placenta –Check the placenta – If it has been expelled If it has been expelled If it is expelled , re examine & make If it is expelled , re examine & make

sure it is sure it is complete. complete. Examine vagina, perineum and cervix for Examine vagina, perineum and cervix for

tears.tears.


Save blood for lab test

Draw & Send The blood for lab test

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Step 1Step 1Postpartum Hemorrhage

AAssess the

shockAssess the cause.Arrange for blood.

AAssess the

shockAssess the cause.Arrange for blood.

BBig bore cannula (16g)

BBig bore cannula (16g)

CCBCCross matchCoagulation screen

CCBCCross matchCoagulation screen

A = AirwayB = BreathingC = Circulation

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REMEMBER - 4Ts

Tone - Uterine atony. (Commonest)

Tissue - Retained tissue/ clots.

Trauma - Laceration, rupture,

inversion.

Thrombin - Coagulopathy.

Postpartum Hemorrhage AETIOLOGY

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Assessment Assessment of Shockof Shock


CompensatiCompensationon

MildMild ModerateModerate SevereSevere

SymptomSymptoms & signss & signs

Palpitation, Palpitation, dizziness, dizziness, tachycardiatachycardia

Weakness, Weakness, sweating, sweating, tachycarditachycardiaa

RestlessneRestlessness, pallor, ss, pallor, oliguriaoliguria

Collapse, Collapse, air-air-hunger, hunger, anuriaanuria

BP BP (Systolic)(Systolic) NormalNormal

Slight fallSlight fall

80-80-100mmHg100mmHg

Marked Marked fallfall

70-70-80mmHg80mmHg

Profound Profound fallfall

50-50-70mmHg70mmHg

Blood Blood losslossBlood Blood volumevolume

500-500-1000ml1000ml

10-15%10-15%

1000-1000-1500ml1500ml

15-25%15-25%

1500-1500-2000ml2000ml

25-35%25-35%

2000-2000-3000ml3000ml

35-45%35-45%

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Step 2Step 2Postpartum Hemorrhage STEP 2- DIRECTED THRPAPY

IMMEDIATE PPH- PALPATE UTERUS

Placenta Expelled completely

Placenta retained/ Partially expelled

ATONIC

Massage UtOxytocics compress

TISSUE

MRP/ Evacuate

SOFT UTERUS

Fundus not felt+Shock+Pain

INVERSION

ImmediateRepositionOf uterus

CONTRACTED UTERUS

Complete placenta

TRAUMA

Cervical/Vaginal/Perineal

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OxytocicsOxytocicsPostpartum Hemorrhage

Dose & Dose & routeroute

MaintenaMaintenance dosence dose

Max Max dosedose

frequencfrequencyy

PrecautiPrecaution /CIon /CI

OxytocinOxytocin IV IV infusion infusion 10U/50010U/500ml ml 60dpm60dpm

IV infuse IV infuse 10U/50010U/500ml ml 40dpm40dpm

Not Not more more than than 3lt 3lt

--

ErgometrErgometrine / ine / MethergiMetherginn

IM /IM /

slow IV slow IV of of 0.2mg0.2mg

0.2mg 0.2mg after 15 after 15 min. min.

5 5 doses.doses.

(1mg)(1mg)

44thth hourlyhourly

PIH, PIH, HT, HT, Heart Heart disease.disease.

15methyl 15methyl PGF2PGF2αα

IMIM 250250μμgg

****

250250μμg g afterafter

15mnts15mnts

8 8 dosesdoses

(2mg)(2mg)

15 - 15 - 90mnts90mnts

Asthma, Asthma, heart heart disease.disease.

** NEVER GIVE PROSTAGLANDIN ** NEVER GIVE PROSTAGLANDIN INTRAVENOUSLYINTRAVENOUSLY

IT MIGHT BE FATALIT MIGHT BE FATAL

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Bleeding Bleeding continuescontinues

Think :Think :

COAGULOPATHY ----- COAGULOPATHY ----- Replace factorsReplace factors

THINK OF SHIFTING THE THINK OF SHIFTING THE PATIENTPATIENT

THROMBIN

CoagulopathyCause/result of PPH


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STEP 3STEP 3INTRACTABLE INTRACTABLE

PPHPPH


Get more help- Obstetrician / surgeon- Anaesthesiologist-Haematologist-BT-- Lab & ICU

Get more help- Obstetrician / surgeon- Anaesthesiologist-Haematologist-BT-- Lab & ICU

Local Control-Manual compression+/- pack uterus+/- vasopressin+/- embolisation

Local Control-Manual compression+/- pack uterus+/- vasopressin+/- embolisation

BP & Coagulation- Crystalloids- blood products

BP & Coagulation- Crystalloids- blood products

Time to shift

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WHERE TO WHERE TO SHIFT?SHIFT?

DDelay in shifting is an important elay in shifting is an important cause ofcause of D Deatheath

Think of shifting as early as possible.Think of shifting as early as possible. Shift as quickly as possible.Shift as quickly as possible. Communicate- to patient /attendantCommunicate- to patient /attendant - to the tertiary care personnel- to the tertiary care personnel

Shift to a tertiary care centre with:Shift to a tertiary care centre with: OTOT ICU ICU Blood bankBlood bank PersonnelPersonnel


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HOW TO HOW TO SHIFT?SHIFT?

Shift preferably in an ambulance,Shift preferably in an ambulance, With nasal oxygen on flowWith nasal oxygen on flow With 2 IV lines with fluid on flow (With 2 IV lines with fluid on flow (it can be it can be

lifelinelifeline)) Document Document

The events in sequenceThe events in sequence IV fluids givenIV fluids given Drugs administeredDrugs administered

Communicate to personnel at tertiary care Communicate to personnel at tertiary care centre.centre.


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Surgery-donot hesitate

Repair lacerations

Ligate VesselsStepwise

Hysterectomy( life saving )

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Debriefing

Discussions

Documentation

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Management – Bimanual

massage


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Replacement of Inverted Uterus


ppp-pph

Documents

india rest

maternal deaths

lakh live births

post partum

developing country

complications of pregnancy

leading cause

hrs of delivery