PPH DRILL SAFOG

PPH DRILL SAFOG

1. SAFOG SESSION @FIGO

PPH MANAGEMENT DRILL
HOW SHOULD WE DO IT ?

Prof Narendra Malhotra
Prof Jaideep Malhotra
OBS TEAM OF MNMH
&
GLOBAL RAINBOW HEALTH CARE

3. ACTIVE MANAGEMENT OF THIRD STAGE
LABOUR
(AMTSL)
Administration of
uterotonic drugs within
1 min of delivery of
baby
OXYTOCIN
<1 min of delivery of baby,
5 units IV bolus/
10 units IM /
10 units / 500ml NS
( 30-40drops/min)
Controlled
cord traction
PREVENTION
Uterine massage
after
delivery of placenta

4. Be Ready for it all the time

•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

5. PPH is an emergency which kills
fast….(golden hour) so we have to be
ready and prepared
•infrastructure preparedness
•Drugs and injections and iv fluids
•Emergency trays and trolleys
•Staff and team work
•Refferals and transport if needed

6. 7

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

8. Large bore IV cannulas (gauge 14 x 2)
Crystalloids

9. PPH Drug Kit
OXYTOCIN 5 amps
METHERGIN 2 amps
PROSTODIN 250 µg 2 amps
Misoprostol 600 µg 1 tab

11. Tranexamic acid belongs to a class of
medication called as antifibrinolytic. It
prevents bleeding during heavy menstruation,
surgery or clotting disorders by not allowing
the blood clots formed in your body to break
down.

13. 14
3 Ds causing the 4th D(eath)
•1. Delay in recognizing & seeking help.


•2. Delay in transport & reaching medical
facility.


•3. Delay in receiving an adequate &
comprehensive care upon arrival

How to diagnose
When to shift?
What & how to give early & appropriate treatment ?

14. Maternal mortality due to PPH
CONFIDENTIAL ENQUIRY INTO
MATERNAL DEATHS

TOO LITTLE – TOO LATE
Too Little (IV fluids, oxytocics, BLOOD,
Clotting factors)
Too Late (PG, resuscitation - blood
replacement, decision for surgery + to
get senior surgeon & anaesthetist
involved)

15. 16



•Anticipate PPH
•Identify PPH / Recognize PPH
•Manage PPH efficiently without delay
•Prevent maternal death
OBJECTIVES
PRACTICAL TEACHING
& STRUCTURED APPROACH

17. THE OBSTETRIC DRILLS
PPH
ECLAMPSIA
DELIVERY(VAGINAL/C SECTION)

18. Drills
Preparations for a drill
The staff that are going to be involved should be
faced with the drill in a normal clinical area,
unprepared, in order to receive a realistic idea of
what would happen in a true situation.
The lead clinician for the teaching session should,
however, have informed the lead midwife and, in
the case of an obstetric hemorrhage, the
transfusion hematologist and other necessary
individuals, such as transportation staff.

19. Communication
Five requirement for effective
communication are:

1.FORMULATED
2.ADDRESSED TO SPECIFIC
INDIVIDUAL
3.DELIVERED
4.HEARD
5.UNDERSTOOD AND ACTED ON

20. 1. FORMULATED
Give a clear message. It should be
succinct and not rambling.

USUALLY IN PANIC AND EMERGENCY
SITUATION WE LOOSE OUR COOL
AND EITHER START YELLING OR
MUMBLING,THIS CONFUSES THE
TEAM

21. 2. ADDRESSED TO SPECIFIC
INDIVIDUALS
Use names of staff and allocate
appropriate tasks to an identified
recipient.
eg GUDDU GIVE
INJECTION
CARBOPROST 250 STAT
Or
SISTER JOHN GIVE METHERGIN STAT

22. 3. DELIVERED
The message should be sent clearly, concisely and calmly: When the
Obstetric emergency team arrives in your room.
THE ATTENDING DOCTOR SHOULD CLEARLY AND PRECISELY QUICKLY
EXPLAIN THE SEQUENCE OF EVENTS
“she has delivered uneventfully 30 mins
back,uterus is not contracting,no high risk
factors,inj methegin given ,inj prostadin 250 IMI
given,wide bore IV started , blood sample
sent…massage being done, we now need to
explore”

23. 4. HEARD
Adequate volume used and
repeated back
THE OBST EMERGENCY TEAM(PPH
TEAM) SHOULD ACKNOWLEDGE
AND IF NEEDED REPEAT SO THAT IT
IS CONVEYED THAT THEY HAVE
HEARD EVERYTHING

24. 5. UNDERSTOOD AND ACTED UPON
Meaning acknowledged and action
performed:
AFTER ACKNOWLEDGEMENT THE
EMERGENCY TEAM SHOULD TAKE
OVER AND ACT….WHETHER REPEAT
DRUG,MASSAGE,INSPECT,CALL FOR
OT READY ETC ETC….

25. Team roles and responsibilities
Their primary concern should be the success of the team
not the leader. They should be mutually supportive,
communicate clearly and give regular updates.

PT BETTER
PT DETORIATING
PULSE IMPROVING
BP PICKING UP
BLEEDING CONTROLED
WE NEED TO OPEN HER UP
WHAT DO YOU FEEL WE SHOULD DO NEXT

etc etc

26. Recognising cues for loss of situational
awareness
SHOULD NOT HAPPEN
DRILLS TRAIN FOR SUCH THINGS

•Poor communication
•Inability to plan ahead
•Tunnel vision
•Fixation on irrelevent issues (such as less than
ideal equipment) or displacement activities such as
unnecessary disputes with colleagues.

27. Maintaining/regaining situational
awareness
To regain control of a situation, the following strategies should
be tried:
•Take the ‘helicopter view’- stand back to get the bigger
picture.
•Declare an emergency-you will engage everyone’s attention
and boost the available human resources.
•Communicate clearly and simply.
•Plan ahead.
•Delegate appropriately.

28. Assessment sheet for massive obstetric
hemorrhage drill.
•Time emergency buzzer pulled.
•Staff responding to the initial buzzer.
•Time switchboard received emergency call.
•Staff responding to the emergency bleep.
•Initial treatment of ABC (airway, breathing and circulation)
resuscitation instituted quickly and effectively.
•Time transportation person arrives in blood transfusion.
•Time blood samples received in the laboratory.
•Time appropriate blood arrives at patient’s bedside.
•Time patient transferred to the operating theater.

29. Running the drill
Illustrates an example of an assessment sheet for a massive
obstetric hemorrhage drill, suggesting things that can
usefully be monitored: these include the following:


•Who responds to the initial emergency buzzer?
•Is the appropriate emergency call put out?
•How effective is the emergency bleeping system?
•Is transportation alerted and does she/he respond?
•Do transfusion staff receive any communication?
•How quickly does blood arrive at the bedside?
•How quickly is the patient transferred to the operating
theater?
•When does the anesthetist/consultant/hematologist arrive?

31. 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

32. Monitor
Identify
Trigger
Alert Evaluate
Diagnose
Respond
MATERNAL
EARLY
WARNING
SYSTEM

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

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

36. Blood loss – quick quiz 2
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

37. Blood loss – quick quiz 2
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

38. Blood loss – quick quiz 3
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

39. Blood loss – quick quiz 3
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

40. Blood loss – quick quiz 4
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

41. Blood loss – quick quiz 4
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

42. Blood loss – quick quiz 5
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

43. Blood loss – quick quiz 5
•0 - 500 mls?
•500 - 1000 mls?
•1000 - 1500 mls?
•1500 - 2000 mls?
•2000 - 2500 mls?
•>2500 mls?

44. pph
•HAEMOSTASIS ALGORITHM

&

•RULE OF 30

45. Alogrithm for management of Atonic PPH
‘HAEMOSTASIS’
H - Ask for Help

A - Assess vital parameters & blood loss and
Resuscitate – (Rule of 30)

E -Establish etiology + Ecbolics
(syntometrine, ergometrine, bolus syntocinon)
+ Ensure availability of blood.

M -Massage Uterus – bimanual compression

O -Oxytocin infusion / prostaglandins -
intravenous / per rectal / intramuscular / intra-
myometrial

46. Alogrithm for management of Atonic PPH
‘HAEMOSTASIS’

S - Shock Garment (anti) & Shift to theatre – Aortic
compression/ Bimanual compression

T - (4 T’s) Tissue/ Trauma/Tone/Thrombin >
Tamponade – Balloon / uterine packing
A - Apply compression sutures – B- Lynch /
modified/ +/- Balloon
S - Systematic Pelvic devascularisation – Uterine /
Ovarian / Quadruple / internal iliac

 I - Interventional Radiology – If appropriate,
Uterine artery embolisation

S - Subtotal / Total abdominal hysterectomy

47. Rule of 30 & Shock Index
30% blood loss >moderate shock
Pulse rate – increase >30 bpm
Respiratory rate >30/min
Systolic BP – drop by 30 mm Hg
Urinary output < 30 ml/hour
Haematocrit drop > 30% & to be kept at an absolute
value of > 30

Shock Index = Pulse rate / Systolic BP – Change by
30%
Normal = 0.5 to 0.7 : >0.9 indicates state of shock that
needs urgent resuscitation

48. 49
General Management if PPH..
………………FOLLOW THE DRILL
 Shout for help
 Rapid evaluation of vitals
 Oxygen by mask
 Uterine massage
 Oxytocin 10 U IM
 Site 2 large bore (16G-gray color) IV cannula
 Infuse IV fluid – NS / RL- run it fast
 Catheterize bladder
 Check the placenta –
 If it has been expelled
 If it is expelled , re examine & make sure it is
complete
 Examine vagina, perineum and cervix for tears
Save blood for
lab test
Draw & Send
The blood for lab test

49. “

“An error doesn't
become a mistake
until you refuse to
learn from it”
Orlando Battista

50. What is
the NASG?

51. 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

52. Innovations in Triage and Treatment of
Obstetric Haemorrhage : THE DRILL BE
READY
PRESENTED BY
PROF. NARENDRA MALHOTRA
MD,FICOG,FICMCH,FICS,FRCOG
DR SHEELA MANE
PROF JAIDEEP MALHOTRA
PROF SUELLEN MILLER

© Suellen Miller, 2016

54. Pressure Bag

55. Developed by King’s College London,
Prof. Andrew Sheenan, Hannah Nathan,
Natasha Helzegrave
CRADLE/Microlife
Traffic Light Vital Sign
Alert
(VSA)
© Suellen Miller, 2016

56. 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
© Suellen Miller, 2016

57. 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.
© Suellen Miller, 2016

58. Improving on Current Treatments
© Suellen Miller, 2016

60. INDIAN INNOVATIONS
•DEBDAS BLOOD ESTIMATION SYSTEM
•CONDOM BALLON TAMPONADE
•UTERINE PACKING

© Suellen Miller, 2016

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

63. PPH
•When medical management
fails, promptly resort to
surgical approach
•“Golden two hours to save the
patient” may not always work

64. Bimanual uterine compression

65. Cervical inspection set
Interrupted stitches

Stitch tears > 1 cms , even if it is not bleeding

66. PPH–Vaginal lacerations :general
principles
•Deep interruted bites, beware of
bladder and rectum
•Interrupted stitches
•Keep epithelium on surface
•Bring hymen to hymen

67. PPH– when laparotomy required
•Vertical midline
incision
•Immediately
arrest bleeding

68. PPH– when laparotomy required
•Steps available :
stepwise devascularisation
• brace stitch- B Lynch,
Hayman
obst hysterectomy

69. Obstetric Hysterectomy
•Modify depending on situation
•Proceed to arrest bleeding-
clamp, cut ,drop -till uterines
are tackled
•Sub total hysterectomy in
atonic

70. Int iliac ligation

73. Acknowledgements:
Elizabeth Abu Haider: PATH/SINAPI UBT
Mark Ansermino & Beth Payne: UBC, Phone
Oximeter
Christian Kastrup: UBC,
UBT/CaCO
3/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
© Suellen Miller, 2016

74. MILLENIUM DEVELOPMENT GOALS
Are now
SUSTAINABLE DEVELOPMENTAL GOALS

SAFOG WORKING CLOSELY TOWARDS THIS

THANK YOU

75. Thank you