![Aortic compression
■ Stand on the right side of the woman.
■ Place left fist just above and to the left of the woman's umbilicus (the abdominal aorta
passes slightly to the left of the midline [umbilicus]).
■ Lean over the woman so that your weight increases the pressure on the aorta. You should
be able to feel the aorta against your knuckles. Do not use your arm muscles; this is very
tiring.
■ Before exerting aortic compression, feel the femoral artery for a pulse using the index and
third fingers of the right hand.
■ Once the aorta and femoral pulse have been identified, slowly lean over the woman and
increase the pressure over the aorta to seal it off. To confirm proper sealing of the aorta,
check the femoral pulse.
■ There must be no palpable pulse in the femoral artery if the compression is effective.
Should the pulse become palpable, adjust the left fist and the pressure until the pulse is
gone again.
■ The fingers should be kept on the femoral artery as long as the aorta is compressed to
make sure that the compression is efficient at all times.](https://image.slidesharecdn.com/postpartumhaemorrhage-250703184215-faada929/85/POSTPARTUM-HAEMORRHAGEby-Maj-Taniabose-pptx-35-320.jpg)
POSTPARTUM HAEMORRHAGEby Maj Taniabose.pptx
- 1. POSTPARTUM HAEMORRHAGE Speaker : MAJ Tania Bose
- 2. Introduction ■ Post partum haemorrhage remains a major cause of maternal mortility and morbidity worldwide. Approximately half a million woman die annually from cause related to pregnancy and childbirth. ■ PPH accounts for 25% of all maternal death
- 3. Definition ■ Any amount of bleeding from or into the genital tract following birth of the baby up to the end of puerperium which adversely effect the general condition of the patient evidenced by the rise in pulse rate and falling blood pressure is called postpartum haemorrhage. ■ Average blood loss acc. To WHO Vaginal delivery 500 ml Caesarean delivery 1000 ml Caesarean hysterectomy 1500 ml
- 4. Benedetti’s Classification Of Haemorrhage Haemorrhage clas Blood loss(ml) % loss 1 900 15 2 1200-1500 20-25 3 1800-2100 30-35 4 2400 40
- 5. Incidence ■ In 2015 maternal mortality ratio was 239 per 1,00,000 live births in developing countries, but in developed countries its only 12 per 1,00,000 ■ Thus 99% deaths are in developing countries, in which south Asia contributes one third ■ 25% of total maternal mortality is due to PPH ■ In India maternal mortality rate is 560 per 1,00,000 ■ PPH accounts for 35-56% of maternal deaths ■ In our hospital rate is 0.4%
- 6. Types ■ Primary PPH – Haemorrhage occurs within 24 hours following the birth of baby. In majority of cases haemorrhage occurs within two hours of the delivery. Two types of primary PPH 1. Third stage PPH -bleeding occurs before expulsion of the placenta 2. True PPH- bleeding occurs subsequent to expulsion of placenta ■ Secondary PPH- haemorrhage occurs beyond 24 hrs and within puerperium also called delayed or late puerperal haemorrhage
- 7. Primary PPH Tone (abnormal uterine contraction) Atonic uterus(80%) Tissue(retained product of conception) Trauma (to genital tract) Thrombin(abnormality of coagulation) 4 t”S
- 8. Atonic uterus Grand multipara Anaesthesia Overdistention of uterus Malformation of uterus Malnutrition and anaemia Uterine fibroid Antepartum haemorrhage Mismanaged third stage Prolonged labour Placenta
- 9. Diagnosis and clinical effects ■ Vaginal bleeding is visible outside ■ State of uterus as felt per abdomen give reliable clue as regards the cause of bleeding ■ The effects of blood loss depends upon I. Pre delivery Hb II. Degree of pregnancy induced hypervolaemia III. Speed at which blood loss occurs
- 10. Clinical effects Pallor,sweating Tachycardia, tachypnea Hypotension Altered level of consciousness Restlessness Drowsiness Maternal collapse
- 12. Underestimation of blood loss
- 13. Calibrated bag
- 14. Estimated blood loss >500ml >1000ml 0 5 10 15 20 25 30 Chart Title visual measured
- 15. Management Identify the patient at risk Multidisciplinary haemorrhagic protocol Clinical management of pph
- 16. 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- I.V. access 6.- Modify obstetrical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management
- 17. Advantage of haemodilution Initial Hb Blood loss Hb loss Preop 45%15g Hb% 2,000cc 300g (27%) Preop 30% 10g Hb% 3,000cc 300g (27%) After hemodilution
- 18. Management of third stage bleeding Principles To empty the uterus To replace the blood To ensure effective haemostasis
- 19. Steps of management • Palpate , massage and make it hard • To start normal saline drip with oxytocin and arrange blood for transfusion • Catheterise the bladder Placenta separated Not separated Express the placenta out By control cord traction Manual removal under GA Traumatic haemorrhage should be tackled by sutures
- 20. Controlled cord traction ■ Place the other hand just above the woman's pubic bone and stabilize the uterus by applying counter-pressure during controlled cord traction. ■ Keep slight tension on the cord and await a strong uterine contraction (2–3 minutes). ■ With the strong uterine contraction, encourage the mother to push and very gently pull cord downward to deliver the placenta. ■ Continue to apply counter-pressure to the uterus. ■ If the placenta does not descend during 30–40 seconds of controlled cord traction, do not continue to pull on the cord: ■ Gently hold the cord and wait until the uterus is well contracted again. ■ With the next contraction, repeat controlled cord traction with counter-pressure. ■ Never apply cord traction (gentle pull) without applying countertraction (push) above the pubic bone on a well-contracted uterus.
- 22. Manual removal of placenta
- 23. Management of true postpartum haemorrhage Immediate measures • Call for extra help • Commence iv line with two wide bore cannula • Send blood for cross matching • Rapidly infuse normal saline/haemoccel 2 litres To feel the uterus by abdominal palpation Uterus atonic Uterus hard and contracted, then exploration and haemostatic suture on the tear site
- 24. Uterus atonic • Massage the uterus to make it hard • To add oxytocin 10-20 unit in 500 ml of normal saline /40 drops per unit • Inj. Methergin 0.2 mg iv slowly • To examine the expelled placenta • To catheterise the bladder Uterus remain atonic • Exploration of the uterus • Blood transfusion • To continue oxytocin drip Uterus atonic • Carboprost 0.25 mg IM or • Misoprostol 600-1000 mcg per rectum Uterus atonic
- 25. Uterine tamponade • Bimanual compression • Balloon tamponade • Aortic compression Uterus atonic Surgical methods Hysterectomy
- 26. New who recommendation,oct. 2017 ■ In march 2017 findings of The World Maternal Antifibrinolytics trial was published ■ Nearly 200 hospitals in21 countries participated in trial ■ In this trial Tranexamic acid 1gm IV given in addition to usual care If bleeding continued after 30 min. or stopped and restarted within 24 hours of the first dose ,second dose was given
- 27. Bimanual compression ■ Place one hand in the vagina and clench hand into a fist. ■ Place other hand on the fundus of the uterus. ■ Bring the 2 hands together to squeeze the uterus between them, applying pressure to stop or slow the bleeding. ■ Keep the uterus compressed until able to gain medical support.
- 29. Procedure ■ Preparation of the CG Balloon— cutting two rings from the drainage tube of Foley’s catheter. ■ Excision of the bulb of catheter subsequent to inflation with 2–5 ml of air. ■ Rolling of condom over catheter. ■ Tying condom to catheter using the rings twice around both the ends of condom leaving 1.5–2 cm of condom on either end. ■ Excision of the tip of Foley’s along with the blind end of condom together 0.5 cm away from the tied ring. Leaving both the rings with CG Balloon
- 33. Uterine tamponade Indications ■ Postpartum hemorrhage due to atony, when uterine massage, uterotonics, and bimanual compression have failed to stop the bleeding ■ When temporary control of PPH is needed before referring the client to a higher level of care Contraindications ■ Arterial bleeding requiring surgical exploration or angiographic embolization ■ Cases requiring hysterectomy ■ Untreated uterine anomaly, cervical or uterine cancer ■ Uterine infections ■ Disseminated intravascular coagulation ■ A surgical site that would prohibit the device from effectively controlling bleeding ■ Lack of trained provider
- 34. Deflation ■ When client is stable (after 12–24 hours), slowly deflate condom by letting out 200 mL of saline every hour. ■ Re-inflate to previous level if bleeding reoccurs while deflating. (Persistent or recurrent bleeding is an indication to proceed with another treatment option.) ■ Re-inflate as a temporary measure and reconsider surgical intervention. ■ UBT may be kept in place for up to 24 hours.
- 35. Aortic compression ■ Stand on the right side of the woman. ■ Place left fist just above and to the left of the woman's umbilicus (the abdominal aorta passes slightly to the left of the midline [umbilicus]). ■ Lean over the woman so that your weight increases the pressure on the aorta. You should be able to feel the aorta against your knuckles. Do not use your arm muscles; this is very tiring. ■ Before exerting aortic compression, feel the femoral artery for a pulse using the index and third fingers of the right hand. ■ Once the aorta and femoral pulse have been identified, slowly lean over the woman and increase the pressure over the aorta to seal it off. To confirm proper sealing of the aorta, check the femoral pulse. ■ There must be no palpable pulse in the femoral artery if the compression is effective. Should the pulse become palpable, adjust the left fist and the pressure until the pulse is gone again. ■ The fingers should be kept on the femoral artery as long as the aorta is compressed to make sure that the compression is efficient at all times.
- 38. Pelvic Artery Ligation- Uterine,Ovarian, Vaginal, Internal iliac Artery
- 40. Management of Secondary PPH SUPPORTIVE • Blood transfusion • Administer methergin 0.2 mg • Administer antibiotics CONSERVATIVE • Slight bleeding • Detain for 24 hrs for observation ACTIVE • Explore the uterus under GA • Remove retained product of placenta if present
- 41. Prevention of PPH ■ Antenatal i. Improvement of the heath status ii. High risk patients iii. Blood grouping iv. Placental localisation
- 42. Intranatal ■ Active management of third stage ■ Cases with induced or augmented labour with oxytocin ■ Woman delivered by caesarean section ■ Observation about two hours ■ Examination of the placenta
- 43. Summary H • Get help A • Immediate action E • Identify the etiology M • Management o • Proceed with oxytocin infusion ;prostaglandins s • Shift to theatre T • Balloon tamponade A • Apply sutures s • Rescue surgery I • Interventional radiology s • Subtotal or total hysterectomy