Pph drill

1. Dr. Monika Madaan
Specialist
Dept. Of Obstetrics & Gynaecology
ESI Hospital
Manesar

2. PPH
Single most important cause of maternal
mortality worldwide.
Accounts for 34% of maternal deaths in
developing countries.

3. Definition
Any blood loss than has potential to
produce or produces hemodynamic
instability

4. Definition
Blood loss > 500 ml after delivery
Primary : Loss within 1
st
24 hours after
delivery
Secondary : 24 hours till 12 weeks postnatally
Minor : 500-1000 ml
Moderate : 1000-2000 ml
Severe : > 2000 ml

5. PREDICTION AND PREVENTION
Identify pt. at risk
- Pl previa/accreta
-Anticoagulation Rx
-Coagulopathy
-Overdistended uterus
-Grand multiparity
-Abn labor pattern
-Chorioamnionitis
-Large myomas
-Previous history of PPH

6. PREDICTION AND PREVENTION
Active Management Of Third Stage Of Labor
(AMTSL): Should be offered routinely and
includes:
1.Administration of uterotonics soon after birth.
2.Delayed cord clamping.
3.Delivery of placenta by controlled cord
traction followed by uterine massage.

7. PPH Drill
Clear and logical sequence of steps
essential in the management of PPH.

8. CALL
FOR
HELP

9. Team Effort
•Skilled Obstetric Team
•Trained
Anaesthesiologist
•Clinical hematologist
•Supporting staff

10. Resuscitation
Assess
A : Airway
B : Breathing
C : Circulation
Secure 2 wide bore i.v. lines:- 14-16 gauge
Draw blood for grouping & cross matching,
CBC, LFT/KFT, SE & Coagulogram.

11. Position flat
Keep the patient warm
Administer oxygen by mask ( @ 10-15 litres/
min)
Catheterize the patient for emptying bladder &
monitoring output

12. Fluid Replacement
RAPID WARMED infusion of fluids
Crystalloids : Fluids of choice until
compatible blood is arranged
1 ml of blood loss= 3 ml of crystalloids
Total volume of 3.5 litres of clear fluids
(upto 2 litres of crystalloids followed by 1.5
litres of warmed colloid )may be given while
awaiting compatible blood.

13. If hemorrhage is torrential
& fully cross-matched
blood still not available :
Uncrossmatched O
negative blood may be
given

14. FFP: 4 Units for every 6 Units of red cells OR
PT/ APTT > 1.5 X normal
(ie 12-15 ml/kg or total of 1 litres.)
Platelet Concentrate: if Platelet count< 50,000/
microlitre.
Cryoprecipitate: if fibrinogen < 1 g/ l.

15. Continuous vital monitoring.
Monitor adequacy of replacement with urine
output (0.5 ml/kg/hr) and CVP (4-8 cm water)
Main therapeutic goals are to maintain:
Haemoglobin > 8gm/dl
Platelet count > 75 × 10
9
/ l
Prothrombin < 1.5 × mean control
APTT < 1.5 × mean control
Fibrinogen > 1 gm/ l

16. Establish Etiology Simultaneously
4 T’s
Tone (abnormalities of uterine contraction) :
70 – 80%
Trauma (of the genital tract) : 20 %
Tissue (retained products of conception) : 10
%
Thrombin (abnormalities of coagulation) : 1 %

17. Contd…

18. Bimanual
Compression
If uterus is
relaxed :
massaging the
uterus will expel
any retained bits &
stimulate uterine
contractions

19. Administer Uterotonic Drugs
FIRST LINE
Oxytocin:
Start with 5 units slow iv or im.
Infusion of 20 units in 1 L@ 60 dr/min.
Continue same dose @ 40 dr/min until bleeding stops.
Maximum upto 3 L.
SECOND LINE
Ergometrine/ methyl ergometrine:
Dose: 0.2 mg im or slow iv
Repeat 0.2 mg after 15 min.
Maximum 5 doses (1 mg)
Syntometrine im

20. THIRD LINE
PGF 2α:
Dose: 0.25 mg im.
Can be repeated every 15 min.
Maximum upto 2 mg or 8 doses.
Misoprostol:
200-800 µg sublingually.
Do not exceed 800 µg
WHO GUIDELINES FOR MANAGEMENT OF PPH 2009

21. Uterine Tamponade
• Bakri balloon
• Sengstaken Blakemore
oesophageal catheter
• Condom catheter
• Urological Rusch
balloon
Success depends upon
Positive Tamponade test

22. Procedure of condom Balloon
insertion

Initial Assembly
 Condoms-2
 Foley’s catheter-no.16
 Saline with iv set
 Speculum
 Sponge holding
forceps

23. Procedure
Lithotomy position
Indwelling Foley’s
catheter.
Explore uterus, cervix and
vagina.
Inflate balloon with 100-
300 ml warm 0.9% Sodium
chloride until bleeding is
controlled (Positive
Tamponade Test).

24. Compression sutures
B Lynch Suture
•Fundal
compression suture
•Apposes anterior
& posterior wall

25. Contd…
Parallel Vertical compression sutures for placenta
praevia

26. Stepwise Uterine Devascularization
•Uterine arteries
•Tubal branch of ovarian
artery
•Internal iliac artery

27. Uterine Artery Embolization
Possible only if internal
artery ligation has not
been done and facility
for interventional
radiology available

28. Hysterectomy
Resort to hysterectomy “SOONER RATHER
THAN LATER”
High maternal morbidity
Timing and adequate replacement is of utmost
importance

29. Documentation and Debriefing
Important to record:
Sequence of events
Time and sequence of admn of
pharmacological agents, fluids, blood products
The time of surgical intervention
The condition of mother throughout .

30. Newer Developments
Tranexamic acid : 1 gm i.v slow. Can be
repeated after 30 min if bleeding continues./
Recombinant activated factor VII
(Novoseven): 90 µg/ kg . May be repeated
within 15-30 minutes. No clear consensus on
efficacy.
Carbetocin (oxytocin agonist) : 100 µg i.v or
i.m. Produces tetanic uterine contractions.

31. HAEMOSTASIS ALGORITHM
H – Ask for help
A – Assess and resuscitate
E – Establish etiology
M – Massage the uterus
O – Oxytocic administration
S – Shift to OT
T – Tissue n trauma to be excluded and proceed to
tamponade
A – Apply compression sutures
S – Systematic pelvic devascularisation
I – Interventional radiology
S – Subtotal or total hysterectomy

32. To Conclude, Management of
PPH Has Evolved From:
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness

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