PREVENTION OF POST PARTUM HAEMORRHAGE BY DR SHASHWAT JANI
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Prevention of postpartum hemorrhage is critical as blood loss within 2 hours of onset can result in death if 25% of blood volume is lost. Regular antenatal care, identification of high risk cases, delivery in well-equipped hospitals, and active management of the third stage of labor can prevent most cases. Active management includes immediate administration of uterotonic drugs like oxytocin, delayed clamping of the cord, controlled cord traction, and examination of the placenta. Oxytocin is the preferred uterotonic as it is very effective and does not have the side effect profile of other medications.
PREVENTION OF POST PARTUM HAEMORRHAGE BY DR SHASHWAT JANI
- 1. Prevention of Postpartum Hemorrhage Dr Shashwat Jani
- 3. What really kills a women ?
- 4. PPH Three delays Delay in diagnosis Delay in transfer Delay treatment / management
- 5. PPH Three factors Amount of blood loss Rate of blood loss Health status of woman
- 6. PPH Time interval from onset of PPH to death is 2 hours . By the time clinical signs appear lost 25% of her blood volume
- 7. BUT THESE CAN BE PREVENTED.
- 8. HOW ?
- 9. PREVENTION Regular ANC Correction of anaemia Identification of high risk cases Delivery in hospital with facility for Emergency Obstetric Care. Otherwise transport to the nearest such hospital at the earliest. Keep speedy transport available Local / Regional anaesthesia ACTIVE MANAGEMENT OF 3 RD STAGE OF LABOUR 4 th Stage of labour - Observation, Oxytocin
- 10. Prevention of PPH in labour room Anticipate PPH in every woman in labor Keep emergency tray
- 11. ANTENATAL RISK FACTORS Two-thirds of women have no identifiable risk factors Pre-eclampsia Mediolateral episiotomy Previous PPH Multiple gestation Previous caesarean Obesity
- 12. INTRAPARTUM RISKS Prolonged 2 nd stage Prolonged 3 rd stage > 30 min Mediolateral episiotomy Arrest of descent General anaesthesia Laceration Augmented labour Forceps delivery
- 13. PPH What must be available immediately in every place of delivery to deal such complication ?
- 14. For handling emergencies one must have a crash kit with the following Crash Kit (Emergency Tray)- Whole team with the patients 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 Hydrocortisone Calcium Gluconate Deriphylline Atropine Adrenaline Dopamine, Dobutamine
- 16. THE THIRD STAGE OF LABOUR IS INDEED THE UNFORGIVING STAGE OF LABOUR AS IN IT THERE LURKS MORE UNHERALDED TREACHERY THAN IN FIRST TWO STAGES OF LABOUR COMBINED
- 17. Mechanism of hemostasis Contraction & Retraction of myometrium.‘Living Ligatures or physiological sutures of uterus‘’ (Baskett 1990) Coagulation pathway. Myotamponade.
- 18. Expectant or active management of third stage ?
- 19. AMTSL preferred -Significanty reduces PPH by 60% -Significantly decrease the need for blood transfusion -Need for therapeutic oxytocics was reduced by 80% ( Conclusive evidence from 5 randomised controlled trial and WHO meta-analysis)
- 20. Components of AMTSL Immediate administration of uterotonic drug Delayed clamping of the cord Controlled cord traction Examination of the placenta Palpation of the uterus to ensure contractility every 15 min. for at least 2 hrs.
- 21. OXYTOCIN PREFERRED Oxytocin alone is very effective Oxytocin does not have the adverse effect profile as those associated with preparation containing ergot (Mc Donald 2002 ) Oxytocin is more stable when exposed to heat and light than ergot preparations ( Favored by WHO 1993 ) Can be used in settings where storage capabilities is an issue
- 22. When to administer a prophylactic Oxytocin in AMTSL ?
- 23. In the AMTSL prophylactic oxytocin administered intramuscularly after the delivery of the baby ( Bristol and Hinchingbrooke trial )
- 24. Dosage of oxytocin recommended Oxytocin 10 IU administered intramuscularly or 10-20 IU in 500 ml of crystalloid IV At caesarean section oxytocin 5 IU intravenously
- 25. The incidence of Induction of Labour is on the rise . Even otherwise, most women in labour have an IV line . Why not use the convenient Oxytocin to prevent PPH?
- 26. Methyl-ergometrine Onset- 3 to 5 min- IM & 1 min for IV Duration- > 3hrs-IM & 45 Min- IV IV / IM 0.2 mg
- 27. More side effects Nausea Vomiting Hypertension Needs refrigeration (2-8 0 c) Contraindications – Hypertension, cardiac disease etc.,
- 28. PGF 2 α ( Carboprost.)-IM only Strong uterotonic 125 mcg IM can be used for prevention
- 29. PPH
- 30. More side effects Shivering Nausea Vomiting Diarrhoea Abdominal cramps Avoid in asthmatics ( bronchospasm )
- 31. Misoprostol (PGE 1 analogue) Oral / rectal / vaginal/Sublingual – accepted routes of administration Can be kept it room temperature up to 27 0. cheap and can be by an unskilled person
- 32. Misoprostol (PGE 1 ) For prevention – 600 mcg orally immediately after clamping and cutting the cord has been recommended.
- 33. How to Refer ? To proper place Foot end elevated With I.V. drip Blood samples (For grouping & crossmatching) Paramedical staff with emergency drugs Prior information to the place of referral blood group With a note (Diagnosis & treatment given) Attenders – Young adults (for blood)
- 34. Non inflatable anti shock garment
- 35. Thank you….