Pph workshop 1 (9 2013)

Dr. Mohamed El SherbinyMD Ob.& Gyn

Postpartum Hemorrhage (PPH)

Guidelines for Immediate Action “Part I”

Damietta Specialized Hospital Workshop 25-9-2013

Pub Med.

Cochrane library.

SOGC Hemorrhagic Shock Guideline No 115 2002

RCOG Guideline P.Previa No.27 2005

Misoprostol Guidance WHO 2007&FIGO 2009

RCOG Guideline PPH No.52 May 2009

WHO Guidelines PPH 2009

SOGC PPH Guideline No 235 Octob.2009

UpToDate July 2013

Sources of Evidence

1. MetGhamr 23-6-20022. Aswan Syndicate scientific Meeting 3-20063. Dekrnes G Hospital 20064. El Sewas G Hospital Meeting 20065. Damietta Governorate meeting Syndicate 20086. Dakahlia COG Society 8-4-20107. El Manzalla G H Meeting 6-200108. Damietta Specialized Hospital 20119. Samnoud Meeting 3- 2011 10.El Mahlla Meeting 6-201111-17 Zamala 8- 2008 to 7-9-2013 6 Years

Local Scientific Meeting

1. Annual Asute Ob Gyn Conference 20042. Annual Kasr Aini Conference 2006 PPH 3. Annual conference Ob Gyn Banha 20074. Bolak Dakror Ob Gyn Conference 20075. Annual Port Saied Ob Gyn Conference 29-3-20076. Annual Ismailia Conference Ob Gyn 26-7-20077. Annual Zagazig Ob Gyn Conference 1-11-20078. Annual Kasr Aini Ob Gyn Conference 3-4-20089. Pan Arab Ob Gyn Annual Confer. 6 -11 - 2008 o

National Conference

10-Pan Arab Asnnual Conference 6 -11 - 2008 Cairo

11- Conference M C S Mansoura 9- 8 – 2007 12-Gy Obn 6 October Conference 19-3 – 2009

13-ERC RCOG Local Meeting 3-2010 Alexanderia 14- El Azhar Dumyat Annual Conference 201215-Clinical Society of Ob& Gyn, Conference

Mansoura 18-4-2013 16- The 27th Anual Scientific M. of Ob.Gyn

Alexandria 2-3 May 2013

National Conference

1 - The 7th World Congress of Perinatal Medicine in Devolving countries Alexanderia March 29th to 30th 20122 - The XX FIGO World Congress October Italy, 20123 - The 3rd Annual ERC/ELG (RCOG)March

2-3-2013

International Conference

Worldwide postpartum

hemorrhage is the commonest cause of maternal mortality.

(Especially in developing countries (

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National Maternal Study 2000

Guidelines for Immediate Action Before : PreventionA. Identify B. Management Of Established PPH 1 - Communication

2 - Resuscitation

3 - Monitoring and investigation

4 - Arresting the bleeding

Before : Prevention

I - Risk Factors for PPH

2 - Management of Third Stage

I - Risk Factors for PPH

Known Antenatal Risk

Substantial RiskO.RSignificant RiskO.R

Suspected or proven Placental abruption

13Previous PPH3

Known placenta praevia tone

12Asian ethnicity2

Multiple pregnancy5Obesity ( BMI>35 )2

Pre-eclampsia/gestational hypertension

4Anaemia ( <9 g/dl )2

Intra-Partum / Postartum risk Significant riskO.RSignificant riskO.R

Delivery by emergency C.S4 Operative vaginal delivery

2

Delivery by elective C.S2Prolonged labour (>12 hours )

2

Induction of labour2Big baby ( >4kg )2

Retained placenta5Pyrexia in labour 2

Mediolateral episiotomy5Age ( >40yeares, not multipa-rous )

1.4

2 - Management of

Third Stage

Active management of the 3rd stage of

labour lowers maternal blood loss and

reduces the risk of PPH by about 60%.

It should be offered to all women

Management of 3rd Stage

Low-risk Vaginal Deliveries:Oxytocin 10 iu (IM) or

Oxytocin 30 iu IV infusion in1000 mL,150 mL/h *

Management Of Third Stage

High risk V. Deliveries or CS :Oxytocin 5 iu IV over 5 minutes .OrCarbetocin (Oxytocin analogue) 100 µg IV bolus

over 1 minute *

Oxytocin 5-10 iu + Methergin 0.2mg

(Syntometrine ) may be used in the

absence of hypertension (for instance,

antenatal low haemoglobin) as it reduces

the risk of minor PPH (500-1000 ml) but

increases vomiting.

Management of Third Stage

A single 100 µg IV injection of carbetocin is as effective as a continuous 2-h infusion of oxytocin

Carbetocin Vs oxytocin for the prevention

of PP following CS:

Carbetocin is associated with a reduced

use of additional oxytocics

Oxytocics ComparisonMethyle

Ergometrine

(Methergine

OxytocinCarbetocinPabal

Oxytocin analogue Amp 1m :0.1 mg

IVIMIVIMIVIM

Onset of

action

2-3 m2-5m< 1 m3 m< 1 m< 2 m

Contraction

Time

60m3 H1 6 m30 m67 m120 m

Storage< 25°C

Dark storage

< 25°C2-8°C

(refrigerator)22

Clinically IV only

Carbetocin :PabalAt CS, carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonics compared to oxytocin, but there is no difference in the incidence of PPH. Carbetocin is associated with less blood loss compared to syntometrine in the prevention of PPH for at vaginal deliveries and is associated with significantly fewer adverse effects. Further research is needed for the cost-effectiveness of carbetocin as a uterotonic gent.

Su et al Cochrane Systematic Review Apr.2012

Misoprostol is not as effective as oxytocin

but it may be used when oxytocin is not

available, such as the home-birth setting.

Management Of Third Stage

Recommended Dosages600 µg orally or sublingually.

25

The peak of action of misoprostol is not consistent with the 3rd stage ,so it is not as effective as oxytocin

RouteOnset of action

Durationof action

Oral8 min∼2 h

Sublingual11 min∼3 hHighest area under the curve

Vaginal20 min∼4 h

Rectal20-100 min∼4 hLowest area under the curve

Pharmacokinetic Profiles of MisoprostolWhy Orally Or Sublingually?

A:Identify

I -Estimated blood loss 500- 1000 ml & No clinical signs of shock

Measures to facilitate resuscitation should it become necessary.

Close monitoring IV accessCBC ,Blood group and screen

Primary PPH: Definition

Management dependent definition

Minor PPH

II-Estimated blood loss >1000 ml or

clinical signs of shock

Protocol of measures to achieve

resuscitation and haemostasis.

Primary PPH: Definition

Management dependent definition

Major PPH

What Are the Degrees of Shock?

Compensated Hemorrhagic Shock

Mild Hemorrhagic Shock

Moderate Hemorrhagic Shock

Severe Hemorrhagic Shock

31

Compensated Hemorrhagic ShockLoss of ≤ 15% of blood volume may not be

associated with any change in blood BP, pulse, or capillary refill.

As symptoms usually precedes the sign, these symptoms may be presented :

AnxietyRestlessnessFeeling of breathlessness .

Urinary output > 30 mL/h

32

Degree of shock

Blood loss

Signs & symptoms

Mild<20%Anxiety , Sweating & Palpitation

Increased capillary refilling

Cool extremities

Moderate20% to

40%

+ Tachycardia& Tachypnea

Postural hypotension

Oliguria (< 20 mL/h)Severe>40%+ Hypotension

Agitation/confusion

Collapse& Anuria

Signs And Symptoms Of Shock

NB. Blood volume at term: ± 100 ml/kg

1.Communication

2.Resuscitation

3.Monitoring and investigation

4.Arresting the bleeding

Treatment of the underlying disorder (4Ts)

Management of Intractable PPH

Management of Established PPH4 components: undertaken simultaneously:

1-Minor PPHEstimated blood

loss 500- 1000 ml & No clinical signs of

shock(Compensated Shock)

2-Major PPH

II-Estimated blood

loss >1000 ml or


Management Of Established PPH Depends On Degree of Blood Loss

If not at a Hospital, it must be referred

urgently





2-Resusetation Minor PPH <1000

ml &CompensatedMajor PPH >1000 ml or Shock

Intravenous

access one 14-

gauge cannula

Crystalloid infusion.

AB,C : Assess: Airway,

Breathing& Circulation

O2 by mask at 10–15 L/M

14-gauge cannula x2 orange

Transfuse blood rapidly

Until blood is available, IV up

to 3.5 L crystalloid lactated Ringer (± one L of it is colloid)

Keep patient& infusions warm

She had received one L lactated Ringer solution

3-Monitoring and InvestigationMinor PPH <1000 ml

&Compensated)Major PPH >1000 ml or Shock

Venepuncture

(20 ml) for:GroupCBC Coagulation screen

Pulse and BP/15m

Venepuncture (20 ml) for:Crossmatch (≥4 units) CBC & Coagulation screenBasal renal and liver F Ts.

Continuous:P ,BP,RR

Temperature /15 m

Foley C. : urine output

2 cannulae, 14- or 16-gauge

All recorded on a flow chart

Estimated bloodloss 500- 1000 ml &

No clinical signs of shock

(Compensated Shock)

1-Minor PPHII-Estimated blood

loss >1000 ml or

clinical signs of

shock


2-Major PPH


urgently

1.Communication

2.Resuscitation





Management Of Established PPH4 components: undertaken simultaneously:

41

1-CommunicationMinor PPH <1000 ml

&CompensatedMajor PPH >1000 ml or

Shock

Alert first-line obstetric

and anaesthetic staff

trained in the

management of PPH.

ØCall obstetric middle

grade & alert consultantØCall anaesthetic middle grade & alert consultant.ØAlert consultant clinical haematology

ØAlert blood transfusion

laboratory.



ØIntravenous

access one 14-

gauge cannulaØCrystalloid infusion.

ØAB,C : Assess: Airway,

Breathing& CirculationØO2 by mask at 10–15 L/MØ14-gauge cannula x2ØTransfuse blood rapidly ØUntil blood is available, IV up

to 3.5 L crystalloid lactated Ringer (± one L of it is colloid) ØKeep patient& infusions warm

2-Resusetation •Volume replacement must be undertaken on the basis that blood loss is often grossly underestimated.• Compatible blood (supplied in the form of packed RBCs) is the best fluid as soon as available,•If necessary Rh negative O blood.

Massive Blood Loss : What Are The Main Goals Of Management ?

The Main Goals is to maintain:• Haemoglobin > 8g/dl• Platelet count > 75 x 109/l• Prothrombin T < 1.5 x mean control• Activated prothrombin times (APT) < 1.5 x mean control• Fibrinogen > 100mg/dl

ComponentUsual Indicationstarting dose

Packed RBCReplacement of oxygen-carrying capacity

2– 4 Units IV

Fresh frozen plasma

Documented coagulopathy

2–6 Units IV

CryoprecipitateCoagulopathy with low fibrinogen

10–20 Units IV

PlateletsThrombocytopenia/ thrombasthenia with bleeding

6–10 Units IV

Indications For Blood Component Therapy

Packed RBC : Fresh frozen plasma: Platelets = 6:4:1

Intravenous fluid replacement with isotonic crystalloids should be used in preference to colloids for resuscitation of women with PPH.

High doses of colloids :

More expensive

May cause adverse effects

Colloids versus crystalloids ?2-Resusetation

CoagulopathyFresh frozen plasma 4 units for:

Every 6 units of red cells or

Prothrombin time > 1.5 x normal

Activated partial thromboplastin time > 1.5 x normal

(12–15 ml/kg or total 1 litres)

Platelets : if PLT count < 50 x 109 /L

• During the wait lactated Ringer :3mI for every one mI of blood lost (*)

• Ringer’s lactate is preferred over normal saline to avoid hyperchloremic acidosis(**)

• There is no place for hypotonic dextrose solutions (**)

Hypovolumeic Shock

Whole blood is needed when acute hemorrhage is catastrophic.

Whole Blood Vs Component therapy

Component therapy provides better treatment because only the specific component needed is given.

Donor Compatible plasma

Compatible red cells

Compatible platelets

Compatible platelets

Recipient

ABO group

1st choice2nd choice

AA,ABA,OA,ABB,O

BB,ABB,OB,ABA,O

OO,A,B,

AB

OOA,B,AB

ABABAB,A,B,

O

ABA,B,O

Blood Component : Recipient & Donor

3-Monitoring and InvestigationMinor PPH <1000


Venepuncture

(20 ml) for:GroupingCBC Coagulation screen

Pulse and BP/15m

Venepuncture (20 ml) for:Crossmatch (≥4 units) CBC & Coagulation screenBasal renal and liver functions

Continuous: Pulse , BP & RR

Temperature /15 m

Foley catheter: urine output

2 cannulae: 14 or 16 gauge


Poor Man's" Fibrinogen Assay

• If a clot does not form within 6 m or • Clot forms and lyses within 30 m.

A coagulation defect is probably present and the fibrinogen level is

< 150 mg/dl

1.Communication

2.Resuscitation






Arresting The Bleeding

Causes for PPH may be considered to relate to one or more of ‘the four Ts’:

● Tone (abnormalities of uterine contraction)

● Tissue (retained products of conception)

● Trauma (of the genital tract)

● Thrombin (abnormalities of coagulation).

Postpartum HemorrhageEmptying the bladder

40 iu oxytocin in 1000 mL lactated Ringer

Firm fundal massage

Before delivery of the placenta

After delivery of the placenta

Contracted cervix

Partial separation

Placenta Accreta

Uterine Atony

Genital Tract Trauma

Coagulation Disorders

Postpartum Hemorrhage Before Delivery Of The Placenta

Brandt-Andrwes

(Controlled cord traction)Succeeded

Fundal massage &Oxytocin infusion

Continuo oxytocin infusion& fundal massageIntra-umbilical cord injection Misoprostol

(800 g)

Manual Removal

Contracted cervix

Nitroglycerin 500ug iv

Partial separation

Peeling

Placenta Accreta

Hysterectomy Piece meal removal ±Methotrexate /Anti progestrone /Embolization In all cases continue fundal massage &oxytocin infusion

Postpartum Hemorrhage after delivery of the placenta

Firm fundal massage &Oxytocin infusion

Bleeding stopped

Conservative T: Massage & oxytocin infusion

Bleeding not stopped

Firm uterus

Exploration1-Trauma

Repair of lower & upper GT up to Hysterectomy

2-Remnant:Removal

3-Coagulopathy:Reverse

Emptying the bladder

Bimanual compression

Atonic uterus

Uterotonics+

Bleeding

stopped


IntractablePPH


Bimanual Compression

Aortic Compression

Uterotonics(3 lines)

62

First Line UterotonicsFor management of PPH, oxytocin should

be preferred over :Ergometrine aloneFixed-dose combination of ergometrine and oxytocin,CarbetocinProstaglandins.

First Line Uterotonics• Oxytocin (Syntocinon®) 5 units IV over

5 m (± repeated) then

• Infusion (40 u in 500 ml L Ringer at 125 ml/hour).

• Not more than 3 L of IV fluids containing oxytocin.

First Line UterotonicsCarbetocin (Pabal®) , 100µg given as

an IV bolus over 1 minute (Can be

repeated )is an alternative

.

Second Line UterotonicsIf the bleeding does not respond to the 1st-line, Ergometrine will

be the second line:• Ergometrine (Methergin®) IM / IV (slowly): 0.2 mg • Repeat 0.2 mg IM after 15 minutes • If required, give 0.2 mg IM or IV slowly / 4 HMaximum dose :5 doses (Total 1.0 mg) Contraindications :Pre-eclampsia, hypertension, heart disease

Third Line UterotonicsIf the bleeding does not respond

to the 2nd-line treatment:

Prostaglandin / Misoprostol

should be offered.

MisoprostolCytotic®,Mesotac® ,Mesoprost®

The recommended dose:600 µg oral or sublingual1000 µg rectal my be used if these routes are not suitable (efficacy < 50%)

Misoprostol Versus IV Oxytocin

Sublingual misoprostol (800 µg) is clinically equivalent to IV oxytocin (40iu) when used to stop atonic PPH in women who have received oxytocin during the 3rd stage of labour.

Misoprostol Versus IV Oxytocin

In settings in which use of oxytocin is not feasible, misoprostol might be a suitable first-line treatment alternative for post-partum haemorrhage.

Misoprostol• A repeated dose should not be given

unless at ≥ 2 h since the first dose.

• If the initial dose was associated with pyrexia or marked shivering, then at least 6 hours should lapse before the second dose is given.

rFVIIaRecombinant human coagulation

Factor VIIa (rFVIIa): NovoSeven® 90 μg/kg given/2 hours bolus

infusionUnproven Effect

Tranexamic Acid For The Treatment Of Postpartum Haemorrhage

• Tranexamic acid decreases postpartum blood loss after vaginal birth and after CS based on two RCTs of unclear quality which reported only few outcomes.

• Further investigations are needed on efficacy and safety of this regimen for preventing PPH.

Tranexamic Acid For The Treatment Of Postpartum Haemorrhage

“The WOMAN Trial” : Waiting the result

An international randomised, double blind

placebo controlled trial.

The trial will be a large, pragmatic, randomised,

double blind, placebo controlled trial among

15,000 women with a clinical diagnosis of PPH

The patient received :1-Syntocinon 5 units IV over -5iu & (40 u in 500 ml L

Ringer at 125 ml/hour).2-Methergin 0.2 mg/slow IV and other 0.2 mg IM and

repeated after 15 minutes3-600µg misoprostol sublingually

The bleeding subsided for 30 minutes Then the uterus was not responding to treatment or massage and other ± 500 ml of blood were lost.

The case is now categorized as “Major PPH” What is the best line of management?

Return to The case Scenario

1.Communication

2.Resuscitation






PPH After CS : Causes 1- uterine atony 2-Placent previa &placenta accreta/ increta/percreta 3- Trauma: bleeding from the uterine incision or extensions of this incision or bleeding from vaginal or cervical tears or uterine rupture 4- Retained placenta

77

PPH After CS : ManagementUterine atony: Fundal massage and uterotonic drugs (including intrauterine injection ) Truma:Inspection for and repair of lacerations and incisional bleeding. The angles of a transverse incision should be clearly visualized and any retracted vesselsare ligated. The ipsilateral ureter should be identified before bleeding is controlled. 78

Intractable PPH About 10 % of women will not respond to the initial management steps and are considered as intractable PPH. They are caused mainly by •Uterine atony

•Placenta accreta at CS scar

• Difficult trauma repair

•Coagulopathy79

Bimanual Compression


•Placenta Previa accretes at CS scar (PP accreta)


•Coagulopathy

Intractable Postpartum Hemorrhage AlgorithmVaginal delivery

Garment balloon tampnadeArterial embolization

Local Control

Garment

Suellen Miller, 2005

Management of Uterine Atony

If pharmacological measures fail : “Intrauterine balloon tamponade “

is the first-line ‘surgical’ intervention

RCOG Guideline PPH No.52 May 2009 Grade C

Intractable Postpartum Hemorrhage AlgorithmVaginal delivery

Local Control

Garment

Gauze Pack or Balloon Tamponade

Arterial embolization

Bakri Tamponade Balloon

Sengstaken-Blakemore Tube

Condom

Sengstaken–Blakemore tube

Three lumen tube(one for drainage)Volume > 500ml

86

Rüsch Hydrostatic Balloon Catheter

Capacity >500 ml

A 60-ml bladder syringe

can be used

But It does not have a drainage channel to monitor ongoing bleeding after placement.

Available in some urologycenter for controlling prostatic bleeding.

Bakri Balloon

A silicone balloonIt was designed as obstetric tamponadeCapacity 500 cc of sterile salineIt has a drainage channelFDA approved

Bakri et al . Int J Gynaecol Obstet 2001;74:139–42

Bakri Balloon

In contrast to the Bakri balloon, the balloon end of the catheter is flush with the end of the balloon

BT-Cath Balloon

A silicone balloonIt was designed as obstetric tamponadeCapacity 500 cc of sterile salineFDA approved

Condom Balloon Tamponade First used by Akhter et al. 2003 at Bangladesh

A 20 women with PPH using the B-LynchA 23 were managed using the condom catheter

with success rate 100%Simple to use, inexpensive and safe.

Akhter et al . MedGenMed.2003 Sep 11;5(3):38. Bangladesh

Condom has no drainage channel to monitor ongoing bleeding.It is clean but not sterile Availability at theater ?

Condom Balloon Tamponade

Akhter et al . MedGenMed.2003 Sep 11;5(3):38. Bangladesh

Mechanism of Action of Balloon Tamponade

I- Exertion of inward to outward hydrostatic pressure against the uterine wall. This pressure may or may not be in excess of systemic arterial pressure . The net result is reduction in persistentcapillary and venous bleeding from theendometrium and myometrium.

Sinha ,Obstet Gynecol. 2003;102(3):641

Georgiou , BJOG. 2010;117(3):295

Bakri,UpToDate,Aug,2013

Mechanism of Action

II-Direct uterine artery (UA) compression

Decreased UA blood flow has been

observed on ultrasound examination in

patients with an intrauterine

Sengstaken-Blakemore tubeCho et al ,Ultrasound Obstet Gynecol. 2008;32(5):711.

Bakri,UpToDate,Mar.,2013

Indications of Balloon TamponadeIn Management of PPH

1- After vaginal delivery for

“Atonic PPH”. (Success R. :80-100%)

2- After CS with placenta

previa / accreta . (Success R.: 56%)

3-Secondary PPH

Mohamed El Sherbiny MD Ob.& Gyn. Damietta Egypt

Use of a Surgical

Glove to Control

Severe Postpartum

HemorrhageXX FIGO World Congress

October 2012

Mohamed El Sherbiny MD Ob.& Gyn.

Hafez Gewely Egyptian Board Ob Gyn

El Saeid Hammoda : Egyptian Board Ob Gyn

Mohamed El Hennawy MS Ob-Gyn

Ahmad Mohamed El Serbiny MS Ob. Gyn

Damietta Egypt

The Inverted

Glove Balloon

TapenadeEl Sherbiny et al FIGO 2012

The Inverted Glove TapenadeWith aseptic precautions knots are mad on all

fingers of a surgical glove to render it a single cavity

Then the glove is inverted to have a smooth outer surface.

98

finger knotted Inverted Glove

El Sherbiny et al FIGO 2012


The Inverted Glove TapenadeA sterile Foleys catheter is inserted within theglove and tied near the mouth of the glove witha silk thread, and the outer end of the catheter is connected to a saline set.


Then the glove is introduced into the uterine cavity.The cervix is grasped with ring forceps. A long dressing forceps is used to insert the glove balloon catheter into the uterine cavity.Alternatively, the catheter can be inserted manually ±)U/S

Guided(

Glove Tapenade: Insertion


Beside the glove ,other Foleys catheter is also inserted as a drainage channel to monitor ongoing bleeding.




Glove Inflation The glove is inflated with 200-500 mL

normal saline, according to need.A roller gauze is introduced into the vaginal cavity to keep the uterine

balloon in place.The glove and the catheters were kept

for 24 hours, and gradually deflated when bleeding ceased


How To Keep The Tamponade In Situ ?

1-A roller gauze is introduced into the vagina

for packing it.

Other alternative 2-Other glove is introduced into the vaginaand inflated by warm saline. or3-Placement of adjunct cervical cerclage

Results Within 20 minutes the bleeding was

stopped in 22 out of 24 women (92%) in which the glove tamponade was used .

In 2 cases, hysterectomy was required despite successful placement of thecatheter .The fertility of these 2 patientwas not desired.

Results None of the patients went into irreversible shock or death . There was no clinical evidence of intrauterine infection. Nine patients were followed up for subsequent pregnancy and 7 (78%) of them got pregnant within 2 years.

Conclusion The Intrauterine tamponade with a

surgical glove is a simple, safe,

inexpensive, readily available and

effective means of treating massive

atonic postpartum hemorrhage.

Combination of External Compression & Internal Tamponade

Intrauterine balloon (Bakri) can be used incombination with a B-Lynch uterine compression suture to create a "uterine sandwich," whereby the uterus is compressed between the balloon internallyand the compression suture externally

Nelson &O'Brien , Am J Obstet Gynecol. 2007;196(5):

Diemert et al.Am J Obstet Gynecol. 2012;206(1):65.e1

B-Lynch Technique

Periprocedure Monitoring And Care Patients with a negative test (ie, bleeding is not controlled) should proceed to laparotomy Broad spectrum antibiotic prophylaxis Uterotonics Adequate analgesia Monitor for blood loss( pallor, dizziness, hypotension, tachycardia, confusion) Periodic flushing of the drainage port toensure that it has not become occluded by bloodand to remove clots.

Thank YouThank You

Thank You

Thank You

Egypt




2-Major PPH

II-Estimated blood

loss >1000 ml or




urgently



Intravenous

access one 14-

gauge cannula

Crystalloid infusion.

AB,C : Assess: Airway,

Breathing& Circulation

O2 by mask at 10–15 L/M

14-gauge cannula x2 orange

Transfuse blood rapidly

Until blood is available, IV up

to 3.5 L crystalloid lactated Ringer (± one L of it is colloid)

Keep patient& infusions warm

3-Monitoring and InvestigationMinor PPH <1000


Venepuncture

(20 ml) for:GroupingCBC Coagulation screen

Pulse and BP/15m

Venepuncture (20 ml) for:Crossmatch (≥4 units) CBC & Coagulation screenBasal renal and liver functions

Continuous: Pulse , BP & RR

Temperature /15 m

Foley catheter: urine output

2 cannulae: 14 or 16 gauge


Arresting The Bleeding

Causes for PPH may be considered to relate to one or more of ‘the four Ts’:

● Tone (abnormalities of uterine contraction)

● Tissue (retained products of conception)

● Trauma (of the genital tract)

● Thrombin (abnormalities of coagulation).

Postpartum Hemorrhage after delivery of the placenta

Firm fundal massage &Oxytocin infusion

Bleeding stopped

Conservative T: Massage & oxytocin infusion


Firm uterus

Exploration1-Trauma

Repair of lower & upper GT up to Hysterectomy

2-Remnant:Removal

3-Coagulopathy:Reverse

Emptying the bladder

Bimanual compression

Atonic uterus

Uterotonics+

Bleeding

stopped


IntractablePPH


1.Communication

2.Resuscitation







•Placenta accreta at CS scar


•Coagulopathy124

Management of Uterine Atony

If pharmacological measures fail : “Intrauterine balloon tamponade “

is the first-line ‘surgical’ intervention

RCOG Guideline PPH No.52 May 2009 Grade C

Beside the glove ,other Foleys catheter is also inserted as a drainage channel to monitor ongoing bleeding.


Health & Medicine

Pph workshop 1 (9 2013)