PREVENTION OF POST PARTUM HAEMORRHAGE BY DR SHASHWAT JANI

1. Prevention of Prevention of
Postpartum Postpartum
HemorrhageHemorrhage
Dr Shashwat JaniDr Shashwat Jani

2. ACCIDENTS AND ACCIDENTS AND
HAEMORRHAGEHAEMORRHAGE

3. • What really kills a women ?What really kills a women ?

4. PPHPPH
•Three delays Three delays
–Delay in Delay in
diagnosis diagnosis
–Delay in Delay in
transfer transfer
–Delay Delay
treatment / treatment /
management management

5. PPHPPH
•Three Three
factorsfactors
–Amount of Amount of
blood lossblood loss
–Rate of blood Rate of blood
lossloss
–Health status Health status
of womanof woman

6. PPHPPH
•Time intervalTime interval from onset of PPH to from onset of PPH to
death is death is 2 hours2 hours . .
•By the time clinical signs appear lost By the time clinical signs appear lost
25% of her blood volume25% of her blood volume

7. BUTBUT
THESETHESE
CANCAN
BEBE

PREVENTED. PREVENTED.

8. HOW HOW ??

9. PREVENTIONPREVENTION
•Regular ANCRegular ANC
•Correction of anaemiaCorrection of anaemia
•Identification of high risk casesIdentification of high risk cases
•Delivery in hospital with facility for Emergency Obstetric Delivery in hospital with facility for Emergency Obstetric
Care. Care.
•Otherwise transport to the nearest such hospital at the Otherwise transport to the nearest such hospital at the
earliest.earliest.
–Keep speedy transport availableKeep speedy transport available
•Local / Regional anaesthesiaLocal / Regional anaesthesia
•ACTIVE MANAGEMENT OF 3ACTIVE MANAGEMENT OF 3
RDRD
STAGE OF STAGE OF
LABOURLABOUR
•44
thth
Stage of labour - Observation, Oxytocin Stage of labour - Observation, Oxytocin

10. Prevention of PPH in labour roomPrevention of PPH in labour room
 Anticipate PPH in every woman in labor Anticipate PPH in every woman in labor
 Keep emergency trayKeep emergency tray

11. ANTENATAL RISK FACTORSANTENATAL RISK FACTORS
Two-thirds of women have no identifiable Two-thirds of women have no identifiable
risk factorsrisk factors

•Pre-eclampsia Pre-eclampsia
•Mediolateral episiotomyMediolateral episiotomy
•Previous PPH Previous PPH
•Multiple gestation Multiple gestation
•Previous caesarean Previous caesarean
•Obesity Obesity

12. INTRAPARTUM RISKSINTRAPARTUM RISKS
•Prolonged 2Prolonged 2
ndnd
stage stage
•Prolonged 3Prolonged 3
rdrd
stage > 30 min stage > 30 min
•Mediolateral episiotomy Mediolateral episiotomy
•Arrest of descent Arrest of descent
•General anaesthesia General anaesthesia
•Laceration Laceration
•Augmented labour Augmented labour
•Forceps delivery Forceps delivery

13. PPHPPH
•What must be available What must be available
immediately in every place of immediately in every place of
delivery to deal such delivery to deal such
complicationcomplication ??

14. For handling emergencies one must have a crash kit with the following For handling emergencies one must have a crash kit with the following

Brannula (16 ,18 ,20)
Bulbs- grouping and
cross matching
Venesection Set
Syringes/ Gloves
Roller gauze / mops /
sticking plaster, scissor
Foley’s catheter
Drip sets
I. V. Fluids- RL, DNS
Hemacel,
Intubation materials
Oxytocin,Misoprostol
PGF2alpha,Methergin
Oxygen with mask
Crash Kit (Emergency Tray)- Crash Kit (Emergency Tray)-
Whole team with the patientsWhole team with the patients
Hydrocortisone
Calcium Gluconate
Deriphylline
Atropine
Adrenaline
Dopamine, Dobutamine

16. • THE THIRD STAGE OF LABOUR ISTHE THIRD STAGE OF LABOUR IS
INDEED THE UNFORGIVING STAGE INDEED THE UNFORGIVING STAGE
OF LABOUROF LABOUR
ASAS
IN IT THERE LURKS MOREIN IT THERE LURKS MORE
UNHERALDED TREACHERY THAN INUNHERALDED TREACHERY THAN IN
FIRST TWO STAGES OF LABOURFIRST TWO STAGES OF LABOUR
COMBINEDCOMBINED

17. Mechanism of hemostasis Mechanism of hemostasis
•Contraction & Retraction Contraction & Retraction
of myometrium.‘Living of myometrium.‘Living
Ligatures or physiological Ligatures or physiological
sutures of uterus‘’ (Baskett sutures of uterus‘’ (Baskett
1990)1990)
•Coagulation pathway. Coagulation pathway.

•Myotamponade.Myotamponade.

18. • Expectant or active managementExpectant or active management
of third stage ?of third stage ?

19. • AMTSL preferredAMTSL preferred
-Significanty reduces PPH by 60%-Significanty reduces PPH by 60%
-Significantly decrease the need for blood -Significantly decrease the need for blood
transfusiontransfusion
-Need for therapeutic oxytocics was reduced by-Need for therapeutic oxytocics was reduced by
80%80%
( ( Conclusive evidence from 5 randomised controlled trial andConclusive evidence from 5 randomised controlled trial and
WHO meta-analysis)WHO meta-analysis)

20. Components of AMTSL Components of AMTSL
•Immediate administration of uterotonic drugImmediate administration of uterotonic drug
•Delayed clamping of the cordDelayed clamping of the cord
•Controlled cord tractionControlled cord traction
•Examination of the placentaExamination of the placenta
•Palpation of the uterus to ensure contractility every 15 min. Palpation of the uterus to ensure contractility every 15 min.
for at least 2 hrs.for at least 2 hrs.

21. OXYTOCIN PREFERREDOXYTOCIN PREFERRED
•Oxytocin alone is very effective Oxytocin alone is very effective
•Oxytocin does not have the adverse effect Oxytocin does not have the adverse effect
profile as those associated with preparation profile as those associated with preparation
containing ergot containing ergot (Mc Donald 2002 )(Mc Donald 2002 )
•Oxytocin is more stable when exposed to heat Oxytocin is more stable when exposed to heat
and light than ergot preparations and light than ergot preparations ( Favored by WHO 1993( Favored by WHO 1993))
•Can be used in settings where storage Can be used in settings where storage
capabilities is an issuecapabilities is an issue

22. • When to administer a prophylactic When to administer a prophylactic
Oxytocin in AMTSL ?Oxytocin in AMTSL ?

23. •In the AMTSL prophylactic oxytocinIn the AMTSL prophylactic oxytocin
administered intramuscularly after the delivery administered intramuscularly after the delivery
of the baby ( of the baby ( Bristol and Hinchingbrooke trialBristol and Hinchingbrooke trial))

24. •Dosage of oxytocin recommendedDosage of oxytocin recommended
•Oxytocin 10 IU administered intramuscularly or Oxytocin 10 IU administered intramuscularly or
10-20 IU in 500 ml of crystalloid IV10-20 IU in 500 ml of crystalloid IV
•At caesarean section oxytocin 5 IU intravenouslyAt caesarean section oxytocin 5 IU intravenously

25. The incidence of The incidence of
Induction of Labour is Induction of Labour is
on the on the riserise. Even . Even
otherwise, most women otherwise, most women
in labour have an in labour have an IV IV
lineline. Why not use the . Why not use the
convenient convenient OxytocinOxytocin to to
prevent PPH?prevent PPH?

26. Methyl-ergometrineMethyl-ergometrine
•Onset- 3 to 5 min- IM &Onset- 3 to 5 min- IM &
1 min for IV1 min for IV
•Duration-Duration->>3hrs-IM & 45 Min- IV3hrs-IM & 45 Min- IV
•IV / IM 0.2 mgIV / IM 0.2 mg

27. •More side effects More side effects
–Nausea Nausea
–Vomiting Vomiting
–HypertensionHypertension
•Needs refrigeration (2-8Needs refrigeration (2-8
00
c) c)
•Contraindications – Hypertension, cardiac Contraindications – Hypertension, cardiac
disease etc.,disease etc.,

28. PGFPGF
22αα
( Carboprost.)-IM only( Carboprost.)-IM only
•Strong uterotonic Strong uterotonic
•125 mcg IM can be used for prevention125 mcg IM can be used for prevention

29. PPHPPH

30. •More side effectsMore side effects
–Shivering Shivering
–Nausea Nausea
–Vomiting Vomiting
–Diarrhoea Diarrhoea
–Abdominal cramps Abdominal cramps
•Avoid in asthmatics ( bronchospasm )Avoid in asthmatics ( bronchospasm )

31. Misoprostol (PGE Misoprostol (PGE
11 analogue) analogue)
•Oral / rectal / vaginal/Sublingual – accepted Oral / rectal / vaginal/Sublingual – accepted
routes of administrationroutes of administration
•Can be kept it room temperature up to 27Can be kept it room temperature up to 27
0.0.
•cheap and can be by an unskilled personcheap and can be by an unskilled person

32. Misoprostol (PGE Misoprostol (PGE
11))
•For prevention – 600 mcg For prevention – 600 mcg
orally immediately after orally immediately after
clamping and cutting the clamping and cutting the
cord has been recommended.cord has been recommended.

33. How to Refer ? How to Refer ?
To proper placeTo proper place
Foot end elevatedFoot end elevated
With I.V. dripWith I.V. drip
Blood samples (For grouping & crossmatching)Blood samples (For grouping & crossmatching)
Paramedical staff with emergency drugsParamedical staff with emergency drugs
Prior information to the place of referral blood groupPrior information to the place of referral blood group
With a note (Diagnosis & treatment given)With a note (Diagnosis & treatment given)
Attenders – Young adults (for blood)Attenders – Young adults (for blood)

34. Non inflatable anti shock garmentNon inflatable anti shock garment

35. Thank
you….