Postpartum Haemorrhage The enemy within2.ppt

About PPH

3. VITAL EVENTS
TAMIL
NADU
INDIA
Birth rate 16.5 23.8
Death rate 7.4 7.6
Infant mortality rate 37 58
Under 5 mortality rate 50.0 94.9
Maternal mortality ratio (2006) 90 307
Total fertility rate 1.8 3.0
Child sex ratio 942 927
Life expectancy at birth (2001-06)
M 67.0
F 69.8
M 64.1
F 65.4
DEMOGRAPHIC PROFILE -2005

4. PPH –THE MOST COMMON CAUSE OF
MATERNAL MORTALITY
PPH is the most common cause of
maternal mortality
It accounts for 25% of all maternal
deaths worldwide
(Source: WHO, The World Report, 2005)

5. PERCENTAGE OF MATERNAL DEATH DUE TO
OBSTETRIC HEMORRHAGE BY REGION
(Source: Khan KS, Wojdyla D, Say L, et al. WHO analysis of causes of maternal
death: a systematic review. Lancet 2006; 367: 1066-74)

6. DEFINITION
Vaginal bleeding of more than 500 mLafter childbirth:
Bleeding underestimated because visual quantification is
difficult
Blood is mixed with other fluids (amniotic fluid, urine)
and therefore underestimated
Bleeding may occur slowly over several hours and condition
may not be recognized until woman suddenly enters shock

7. Major Cause
Forty seven per cent of maternal deaths in rural India
are attributed to excessive bleeding and anemia
resulting from poor nutritional practices.

8. Heart Disease
16%
PIH
8%
Sepsis / Septicaemia
6%
Thrombophelebitis
15%
Others
15%
Janudice
4%
Post operative
complications
3%
Anaemia and Malnutrition
4%
Rupture uterus
2%
PPH
20%
APH
1%
BOH
1%
Prolonged / Obstructed
labour
1%
Puerperal psychosis
1%
STD/HIV/AIDS 0.49%
Abortion related complication-0.39%
Diabetes-0.29%
Arrested breech-0.39% CAUSE OF DEATH
2007-08

9. Maternal Deaths 2007-08
(Period wise)
22%
4%
74%
ANNPN

10. REASONS FOR HIGH MORTALITY IN PPH
Failure to adequately recognize volume of blood loss
Failure to provide adequate resuscitation
Failure to provide timely treatment for the cause of
PPH
REMEMBER, PPH CAN KILL WITHIN 2 HOURS

11. MEAN INTERVAL FROM ONSET TO DEATH FOR MAJOR
OBSTETRIC COMPLICATIONS

12. RISK FACTORS FOR PPH
Previous PPH
Over distended uterus
Pre-eclampsiaand other medical disorders like anemia
However
2/3 rd of PPH occur in women with NOidentifiable risk
factors

13. THE 4 Ts OF PPH
Tone
70%
Trauma
20%
Tissue
10%
Thrombin
1%
(Source: A textbook of Hemorrhage; Vital Statistics & Overview;
Cameron & Robson; Sapiens 2006)

14. CAUSES OF CONTINUED PP
BLEEDING
TONE
Uterine Atony
Uterine fatigue, caused by prolonged labor or overuse of
oxytocinfor induction
Precipitate labor
Over distension of uterus -polyhydramnios, multiple
gestation, macrosomia
Retained placental fragments/clots
Higher order births

15. TISSUE
Retained placenta/products of conception
TRAUMA
Rupture uterus
Genital tract or perineallacerations
THROMBIN
Bleeding disorders
CAUSES OF CONTINUED PP BLEEDING

16. CURRENT APPROACHES FOR PREVENTING PPH
AND MITIGATING ITS EFFECTS
AMTSL
Including prophylactic use of
standard oxytocics
Early detection of hemorrhage
Using simple techniques
Anti-shock garment
To resuscitate and stabilize for up to 50 hours
till comprehensive care for PPH and shock is
available

17. Active Management of the Third Stage of Labour AMTSL :
Step 1
Step 1: Administer Uterotonic within 1 minute of delivery
Rule out presence of additional baby(s)
Dry and warm the new born
Delivery of baby
Uterotonic of choice; Oxytocin, Ergometrine/
Syntometrine, if no heart disease/BP Misoprostol,
if injectable not possible
Put baby to breast
Wait till pulsation of cord stops
Clamp and cut the cord

18. Active Management of the Third Stage of Labour AMTSL :
Step 2
Stabilize uterus using counter-pressure and gently pull
downward on the cord
Encourage mother to push
Continue applying counter-pressure
Keep slight tension on cord
Await strong uterine contraction
Clamp cord close to perineum
Step 2: Controlled cord traction
Gently hold cord and await next contraction
Repeat controlled cord traction
As placenta delivers, hold in two hands and gently turn until
membranes are twisted on themselves until they slowly deliver

19. Active Management of the Third Stage of Labour AMTSL :
Step 3
Palpate for contracted uterus every 15 minutes
Repeat uterine massage as needed during first 2 hours
Ensure uterus does not become soft after stopping massage
Immediately massage fundus of the uterus until it contracts
Step 3: Massage the uterus
If membranes tear: gently examine cervix; remove any pieces of membrane
visible
Ensure none of the placenta is missing
Take appropriate action, if retained placenta fragments suspected
Teach mother to massage her own uterus as needed

20. INITIAL ASSESSMENT AND MANAGEMENT
Shout for help—mobilize personnel
Evaluate woman’s condition including vital signs
If shock suspected, immediately begin treatment
Catheterize bladder
Give oxytocin 10 units IM

21. INITIAL ASSESSMENT AND MANAGEMENT
Massage uterus to expel clots and feel to see that it is
contracted—recheck intermittently
Infuse IV fluids
Check to see that placenta has been expelled—examine for
completeness
Examine the cervix, vagina and perineum for tears

22. EARLY DETECTION OF HEMORRHAGE
Most common method of assessing blood loss during
delivery:
How reliable are our (gu)estimates?
Visual Estimation of Blood Loss

23. Fallacies of
visual estimation
Soiled Sanitary Towel
30 ML
Saturated Sanitary Towel
100 ml
Saturated Small Swab
10 X 10 cm
60 ml
Incontinence Pad
250 ML
Saturated Swab 45 cm
X 45 cm
350 ML
100 cm Diameter
Floor Spill
1500 ML
PPH on Bed
1000 ML
PPH Spilling to Floor
2000 ML

24. BLOOD COLLECTION DRAPE-SIMPLE TECHNIQUE FOR
ASSESSING BLOOD LOSS

25. Actions for PPH
Cause –Tone, Tissue,trauma and Thrombin
Early management of PPH. Contracted Uterus with
no POC and no tear –may be Coagulopathy.
Only less than 1% due to previously
existing Coagulopathy, Bed side Clotting test to find
DIC>350 ml

26. Actions for PPH
Additional dose of Oxytocin-10-20 units IM.
Additional dose pf Oxytocin in 500 ml of IV Fluid –
40 drops per minute -150 ml/hr .
Methergin 0.2-.4 mg
Mesoprestol-1000 mcg
Watch for retained POC and Trauma
Do a bed side clotting test

27. OxytocicDrugs: Oxytocin
Advantages
Causes uterus to contract
Acts within 2 ½min. when given IM
Generally does not cause side effects
Disadvantages
More expensive than ergometrine
Not heat stable

28. Non Pneumatic Anti Shock
Garment

29. The Non Pnuematic Anti Shock Garment

30. How the NASG works

31. REMEMBER
NASG is not a treatment for PPH
It only helps in managing shock during transportation
or while waiting for definitive interventions

32. Oxytocic Drugs
Oxytocin Ergometrine/
Methylergometrine
15-methyl
prostaglandin F
2
Dose and Route IV: Infuse 20
units in 1 L at 60
drop/min.
IM: 10 units
IM or IV: 0.2 mg IM: 0.25 mg
Continuing Dose IV: Infuse 20
units in 1 L at 40
drop/min.
Repeat 0.2 mg IM
after 15 min. If
required, give 0.2
mg IM or IV every
4 hours
0.25 mg every 15
min.
Maximum Dose Not more than 3 L
of IV fluids
5 doses 8 doses
Precautions/
Contraindications
Do not give as IV
bolus
Pre-eclampsia,
hypertension,
heart disease
Asthma

33. Oxytocic Drugs: Ergometrine
Advantages
Low price
Effect lasts 2–4 hours
Disadvantages
Takes 6–7 minutes to become effective when given IM
Causes tonic uterine contraction
Increased risk of hypertension, vomiting, headache
Contraindicated in women with hypertension or heart
disease
Not heat stable

34. Oxytocic Drugs: Syntometrine
Advantages
Combined effect of rapid action of oxytocin and
sustained action of ergometrine
Disadvantages
Increased risk of hypertension, nausea and vomiting
Not heat stable
More expensive

35. Misoprostol for treatment of PPH
Route of
administration
Dosage
Oral 600 mcg
Sublingual 600 mcg
Rectal 800 –1000 mcg
Caution:
If prophylactic misoprostolgiven less than 2 hours ago, second dose of
misoprostolmust not be given
If patient experienced fever/shivering after prophylactic misoprostol, no
more misoprostolto be given before 8 hours
A recent study shows that misoprostolis equally effective in
treatment of PPH as other uterotonicsand guidelines may change in
near future

36. UNRESPONSIVE UTERINE BLEEDING
Tamponade techniques
gauze, balloons,
condom/glove with
infiltrationofplacentalbedwith
vasoconstrictors
Laparotomy
Conservative
Vessel ligation (uterine,
ovarian , hypogastric )

37. ONSET –DEATH
INTERVAL
( WHO)
PPH -2hrs
APH -6hrs
I would have been alive today, if
they had referred me to GH
with life wrap on. But in the
hospital where I was taken later
they gave me 5 units blood, but
it'was too late
24 hr EmOC

38. The Taj is beautiful; but we don’t need anymore Taj Mahal
Let us join hands in preventing PPH