Dr Sunita Singal,SJH ND

PPH & Shock

Objectives

To detect PPH & assess degree of shock Identify types of PPH To develop skills and best practices for

management of postpartum hemorrhage To describe strategies for prevention of

postpartum hemorrhage

Haemorrhage is common

Most common cause of maternal death worldwide

Probably accounts for more than 30-38% of all maternal deaths

Deaths from haemorrhage could often be avoided

Haemorrhage is often not recognized

Blood loss is underestimated because in pregnancy signs of hypovolaemia do not show until the losses are large

Mother can lose up to 30-35% of circulating blood volume (2000 mls) before showing signs of hypovolaemia

PREVENTION STRATEGY FOR PPH

AMTSL: ACTIVE MANAGEMENT OF THIRD

STAGE OF LABOUR

The classical expectant management

• Wait for the natural forces of labor to bring about 3rd stage contraction and placental separation

• Look for the signs of placental separation• Controlled cord traction to expel the placenta

and membranes• Optional administration of Oxytocics

WHAT IS AMTSL :Active management of 3rd stage

• Oxytocic administration immediately after delivery of the baby so that the uterine contractions & placental separation is not left to the natural uncertain forces of labor

• Controlled cord traction on perception of a strong uterine contraction with out waiting for the actual signs of placental separation

• Uterine massage to maintain the contraction

Benefits of AMTSL

• Uterine atony accounts for 70-90% of all PPH cases

• AMTSL reduces: Incidence of PPH by 60%Quantity of blood loss—thereby decreasing incidence &

severity of anemiaEmergencies & related cost, transportThe use of blood transfusion

PPHaemorrhage - causes

4Ts: Tone: uterine atony, Tissue: retained placenta or retained products, Tears: cervical or perineal, or ruptured uterus), Thrombin: coagulation disorder

Coagulation disorders may also be associated with haemorrhage

Symptoms & signs

Associated findings

Probable diagnosis

Immediate PPH Uterus soft & not contracted

Bleeding may be continuous or Intermittent, Shock

Atonic uterus

Immediate PPHUterus contracted

Bleeding is bright red and continuous (Complete placenta expelled)

Traumatic PPH- tears in the cervix or vagina

Placenta not delivered within 30 min of delivery

PPH may or may not be present

Retained placenta

Diagnosing the cause of PPH

Portion of placenta missing or membranes torn

Uterus relaxed PPH

Retained placental fragments

Uterine fundus not felt on abdominal palpation

Inverted uterus apparent at vulvaImmediate PPH

Inverted uterus

Shock due to Haemorrhage

Shock is a life threatening condition that requires immediate, intensive treatment

The presence of shock mean that there is an inadequate perfusion of organs & cells with oxygenated blood. There is some form of cardiovascular compromise

Signs Present?

When signs are there they are SIGNIFICANT Have a high suspicion and ACT QUICKLY!

Shock due to Haemorrhage –Signs

Pale Confused Increased HR Reduced BP (late sign) Reduced urine output Obvious or hidden bleeding

Signs of shock Brain -unconscious, anxious, agitated and confused, drowsySkin - sweaty or cold and clammyBreathing - rapidConjunctivae - palePulse - weak and fast >100/minute (sometimes “bounding pulse”)BP - low systolic < 90 mmHg (late sign)Kidney - poor urine output

Haemorrhage - management

Follow the protocol

ABCs

C - replace the volume - stop the bleeding

Haemorrhage

ABCs Circulation

IV access by 2 large bore cannulae

Send off blood samples Give iv fluids

16G – GREY: 1 litre in 5 mins

18G – GREEN: 1 litre in 10 mins

20G – PINK: 1 litre in 15 mins

22G – BLUE: litre in 30 mins

Shock- immediate actionCirculation

Get iv access and send blood samples

If pulse>100 / minute or BP< 90 mm Hg or heavy vaginal bleeding Give 1 l iv fluid over 20 minutes Give further 1 l over 30 minutes Review the situation and repeat if necessary

Beware – if underlying anaemia or severe pre-eclampsia

How much fluid, How fast?

• Volume of 3x the estimated loss as crystalloids (up to 4L) then as colloids

• Give blood early – mistake often is too little too late! (So REFER to FRU early)

• Replace as quickly as you can if patient shocked

• Be guided by the patients signs and response (e.g. Pulse rate, level of consciousness)

Be aware of blood lost!Signs Blood lost Action

Mild increase in pulse-

700 mls Give iv fluids

Increase in pulse and respiratory rate

1500 mls Give iv fluids

Fall in BP 2000 mls Give fluids and blood

Cold, drowsy, very high pulse, very low BP

2500 mls Large transfusion required

Shock- immediate actionAscertain the cause of haemorrhageCover her and keep her warmKeep a careful record of input and output and drugs

given

If at a lower level facility, Prompt Referral to FRU after resuscutation

Diagnosing the cause of PPH

The most important step in making a diagnosis of the cause of PPH is to keep a hand on the lower abdomen of the woman and feel for the uterine tone

PPH – How to manage

Stepwise approach in case of uterine atony

Uterine atony

Empty bladder Give Oxytocics Check for

placenta completeness genital tract injury

Rub uterus Bimanual compression Aortic compression Uterine tamponade

Management (Contd.)

Massage uterus to expel clots and feel to see that it is contracted—recheck intermittently

Give oxytocin 10 units IM Give iv fluids Oxygen @6-8 L/ minute by mask

Oxytocic DrugsOxytocin Ergometrine/ 15-methyl

prostaglandin F2

Dose and Route IV: Infuse 20 units in 1 L at 60 drop/min.IM: 10 units

IM 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 every 4 hours

IM: 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

Bimanual Compression of Uterus

Wearing sterile gloves, insert hand into vagina; form fist

Place fist into anterior fornix and apply pressure against anterior wall of uterus

Bimanual Compression of Uterus (contd.)

With other hand, press deeply into abdomen behind uterus, applying pressure against

posterior wall of uterus Maintain compression until bleeding is controlled and uterus contracts

Compression of Abdominal Aorta

Apply downward pressure with closed fist over abdominal aorta directly through abdominal wall

With other hand, palpate femoral pulse to check adequacy of compression- Pulse palpable = inadequate- Pulse not palpable =

adequate

Compression of Abdominal Aorta (Contd.)

• Maintain compression until bleeding is controlled

Uterine Tamponade (1)

Uterine Tamponade (2)

Up to 500mls or until the uterus is contracted

RETAINED PLACENTA: MRP•IV oxytocin, oxygen, Empty bladder, CCT•If CCT not successful, on PV it can be felt in cervix, grasp & remove.•If still cannot be removed, & Cx is dilated,MRP should be attempted give plasma expanders, additionally•If placenta is retained & no bleeding refer to FRU.

Traumatic PPH Episiotomy Perineal tears and lacerations Vaginal tears Cervical tears Uterine rupture Broad ligament hematoma Para-vaginal & Vulval hematoma

Follow-up care in atonic PPH

• Monitor the vital signs( pulse, BP, RR) • every 10 min. for the first 30 mins,

• every 15 mins. for the next 30 mins. & then• every 30mins. for the next 3-6 hours or until stable.

• Palpate the uterine fundus to ensure that the uterus remains contracted.

• Continue oxytocin infusion• Monitor the urinary output - should be more than 30 ml/

hour

Not a common condition Pulling on the umbilical cord in the

absence of a uterine contraction in an effort to deliver the placenta can cause inversion of uterus

Acute Uterine Inversion

Manual replacement of uterus Give the woman IV sedation with Inj.

Pentazocine (Fortwin) 30mg, and Inj. Phenergan 25 mg.

Ensure aseptic precautions Insert a hand into the vagina. Feel for the

cervical rim. Reposit the uterus back, starting with the part

that comes out last (the fundus comes out first and the portion of the uterus just above the cervix comes out last)

Uterine Inversion

‘O’ Sullivan’s hydrostatic pressure method can be attempted (?) if service provider is experienced

Do not remove the placenta, if attached to uterus, before vaginal replacement of the uterus as it can lead to severe hemorrhage

Prevention

Do not pull on the cord in the absence of a uterine contraction.

Always apply "counter-traction" with the other hand while carrying out controlled cord traction.

Do not apply fundal pressure to deliver the baby or the placenta.

DELAYED PPH Management• Give Inj. Oxytocin 10 IU I/M stat• Start IV infusion of 20 IU Oxytocin in 500 ml of Ringer Lactate / Normal saline at rate of 40-60 drops / min• Suspect infection if fever and / or foul smelling vaginal discharge• Give first dose of antibiotics Cap. Ampicillin 1 gm oral Tab. Metronidazole 400 mg oral Inj. Gentamycin 80 mg IM stat• Refer to FRU

KEYPOINTS

• Prevent PPH Practice AMTSL• Diagnose & treat PPH promptly if it occurs• Quick assessment of mother’s condition &

Tx of shock.• Identify the cause of PPH and manage

accordingly.• Timely referral to FRU where blood is

available (after immediate management)

THANK YOU

Dr Sunita Singal,SJH ND

Dr Sunita Singal,SJH ND