For more detailed information, see text on the reverse side of this leaflet  For more detailed information, see text on the reverse side of this leaflet  the safer motherhood STEP STEP Knowledge Transfer Program BEFORE Prevention Immediate Action: Editor-in-Chief: Professor Sir Sabaratnam Arulkumaran Call for HELP Check for: 1 Have someone available at all times to help manage Postpartum Hemorrhage 2

Bleeding postdelivery Uterine massage every 5–10 mins is recommended to Vigilance Uterine Tone is stopped by clotting confirm that the uterus is contracted. Women should In order to identify potential problems promptly, it is critical that health workers remain vigilant during the In parallel with resuscitation, assessment of uterine tone should take place when managing primary in intrauterine vessels be taught to self massage and also advised to warn minutes and first hours following . postpartum hemorrhage because uterine atony is the dominant cause of postpartum hemorrhage. Uterine brought about by staff if the uterine fundus is soft, increasing in size or natural uterine atony is suggested by the presence of a boggy soft uterus. If the uterus is atonic, immediately give 5 IU bolus they have continued bleeding. In responding to early signs of postpartum hemorrhage the first step is to undertake a proper assessment of contractions and is dose of syntocinon intravenously or intramuscularly and manually rub the uterus over the abdomen – which the woman and take immediate, non-specific, life-saving measures (such as resuscitation, monitoring vital enhanced by oxytocin. NB. If oxytocin is not available, administering 400 μg should be continued until the bleeding stops. signs and calling for additional HELP). All the medical and of misoprostol sublingually after the birth of the baby Make sure that the bladder is empty, either by encouraging the woman to achieve this herself or by passing a uterus conserving significantly reduces the occurrence of hemorrhage. The next step is to provide specifically directed therapy once a diagnosis of postpartum hemorrhage has been catheter into the bladder. surgical steps attempt confirmed. In practice, not all diagnostic assessments can be undertaken simultaneously, so the caregiver to facilitate the should try and assess the situation in the light of all the circumstances surrounding the birth. It should be clotting and should be Training Programs and emphasized that recent experience has demonstrated the special value of early hemorrhage control to avoid Trauma performed before coagulopathy sets in. postpartum massive postpartum hemorrhage with coagulopathy. Simulation Training Continued bleeding after uterotonic administration is most likely from unrecognized laceration of the genital Prevention of postpartum hemorrhage (PPH) involves It is recommended that simulations tract, including uterine rupture. Hence, examination of the whole genital tract is essential under a good light the practice of active management of the third stage source, with assistance and appropriate equipment to visualize all of the and cervix. Any bleeding of labor and the identification of those at high risk of postpartum therapy should Resuscitation vessels should be tied and tears sutured. hemorrhage for postpartum hemorrhage, such as patients with be included in in-service Follow a simple ABC approach, as problems with Airway, Breathing, and finally Circulation are identified. prolonged labor, pre-eclampsia, previous postpartum training programs. It has The medical logic behind the ‘ABC’ approach is that an Airway problem will kill the patient more quickly than hemorrhage and multiple . Active also been demonstrated a Breathing problem, which in turn will kill a patient more quickly than a Circulatory (bleeding) problem. Placenta management of the third stage of labor incorporates that good However, C-ABC with attention to arrest bleeding may be more appropriate for postpartum hemorrhage. Inspection of the placenta after delivery must be routine to check for its completeness. three main interventions: communication Check for any missing cotyledon(s) by inspecting the amniotic and chorionic side of the placenta. Guidelines administration of oxytocin or misoprostol or between Airway another uterotonic drug within 1 minute after healthcare In caring for the airway, the cervical spine must be Bimanual Compression the birth of the baby; protected. Place your hand on the patient’s forehead and providers and Insert one gloved hand into the vagina and push up against controlled cord traction (not essential with gently tilt the head back. At the same time, with your for Immediate their patients the body of the uterus. Place the other hand above the oxytocin); and fingertips under the point of the patient’s chin, lift the (and families) can uterine fundus on the abdomen and compress the uterus chin to open the airway. A jaw thrust may be required to uterine massage after delivery of the placenta. have a beneficial result. against the hand in the vagina. To be effective bimanual facilitate this. Action uterine compression has to be maintained effectively for 8–10 mins till the blood clots in the uterine vessels. In a Want to know more about the management of Breathing number of women this is all that is needed. In the others it postpartum hemorrhage? Assess breathing for 10 seconds by looking for chest is a temporary measure in the management of PPH caused movements, listening for breath sounds and feeling for by uterine atony after vaginal delivery. If you would like to know detailed information about postpartum hemorrhage: the movement of air. If no breathing is detected, put out 1. Read and/or download free of charge a 7-minute learning Module (principally designed for midwives NB. This procedure is painful to the woman and is only a cardiac arrest call and administer two rescue breaths. and other professional birth assistants) at www.glowm.com undertaken in cases of PPH if drugs are not available or 2. Read and/or download, free of charge, a 20-minute Masterclass Lecture (principally designed for if drug therapy fails. doctors and doctors in training) at www.glowm.com Circulation 3. Read and/or download, free of charge, the 650 page A Comprehensive Textbook of Postpartum If circulation is present but no breathing, continue rescue breathing at a rate of 10 breaths per minute. Recheck G Hemorrhage at www.glowm.com the circulation every 10 breaths, taking no more than 10 seconds each time. If the patient starts to breathe on THE GLOBAL LIBRARY OF WOMEN’S MEDICINE her own but remains unconscious, turn her into the recovery position and administer oxygen at a rate of This Wall Chart has been written and developed by: Mahantesh Karoshi MD, MRCOG, DCRM, Barnet General Hospital, London, UK, Professor Sir Sabaratnam Arulkumaran MD, PhD, FRCS, FRCOG, St George’s, University of London, UK and 15 liters/minute. www.glowm.com André B. Lalonde MD, FRCSC, FRCOG, University of Ottawa and McGill University, Ottawa, Canada

STEP For more detailed information, see text on the reverse side of this leaflet  STEP For more detailed information, see text on the reverse side of this leaflet  STEP For more detailed information, see text on the reverse side of this leaflet  STEP For more detailed information, see text on the reverse side of this leaflet  Drug Therapy Balloon Seek Additional Hospital-based 3 for Management 4 Tamponade 5 Help 6 procedures © Copyright B-Lynch ’05 Syntocinon/oxytocin Misoprostol PGE1 In women who have not The balloon tamponade can be removed after If the patient continues to hemorrhage, it is important to seek additional help as a matter of priority and plan B-Lynch Suture responded to treatment 4–6 hours, although it is usually left overnight to early referral. The normal chain of patient care involves the following transfers: Use Monocryl suture or Vicryl number 2 Syntocinon/oxytocin Misoprostol with uterotonics stabilize the patient. Once the fluid in the balloon is The B-Lynch suture aims to exert continuous vertical compression on the requires refrigeration does NOT (i.e. drugs) – or if withdrawn, check for bleeding. If there is no further uterine vascular and muscular system. Laparotomy, uterine exteriorization and and must always be require Home Delivery uterotonics are bleeding for 30 minutes, remove the balloon. an opened uterine cavity are always necessary. administered by refrigeration not available – injection. The usual and its cost the use of an Nursing Station or Health Unit dose is 20 IU in 500 ml is low. It is, Other Conservative intrauterine How to use a condom if of crystalloid solution. therefore, Suture Procedures: simple and convenient to use. Three 200 μg tablets balloon should be no alternative is available The intravenous route District or Regional Hospital Vertical Uterine Compression Sutures (i.e. 600 μg in total) can be administered orally or considered in the Open the condom, insert the end of a piece of is used, with the These sutures are an alternative to the 400 µg in powdered form sublingually all at once. treatment of postpartum dosage rate adjusted tubing from an IV set into the condom, tie securely B-Lynch technique if no lower segment cesarean incision is present. hemorrhage due to uterine If necessary, transfer to according to the response with sterile string, insert the condom into the uterus Tertiary (University) Hospital ’05 B-Lynch Copyright © They may be placed without opening the uterus. Misoprostol 400 µg – powder form administered atony. However, this (typical rate 250 ml/h). sublingually has been shown to be more effective than via the cervix, release fluid from the IV bottle down in instances where full therapeutic measures such as blood bank facilities, surgical expertise, intervention does require Cho Multiple Square Compression Sutures oxytocin for prevention of PPH. It is important to ensure the tubing and into the condom (or glove) until it operating theater facilities, or embolization are not available or where there are delays in Intramuscular administration of 10 IU results in a slower training and there are risks Multiple square sutures are used to cover the whole body of the uterus and this that there is no twin – or multiple – sibling still awaiting has expanded fully between the walls receiving these therapies or for intensive care monitoring in a patient who continues to bleed. onset of action (3–7 min) but with a longer-lasting effect associated with the procedure © Copyright may be useful in placenta previa. delivery before the drug is administered). Misoprostol B-Lynch ’05 of the uterus. (up to 60 min). such as infection and perforation administered as powder sublingually brings about of the uterus. A Sengstaken tube, Rüsch balloon, immediate contractions compared to the other routes of NB. To see a video Anti-shock garment Uterine Artery Embolization The preferred storage of oxytocin is refrigeration but it Bakri balloon and even an inflated condom or glove administration. Repeat doses are not recommended. demonstration of this The best method of keeping a woman stable while transferring her is to A patient must be sufficiently stable to transport to the angiography suite. may be stored at temperatures of up to 30ºC for up to have been used with success. 3 months without significant loss of potency. procedure, go to www.glowm.com use a non-inflatable anti-shock garment (NASG) if available. This in itself Embolization should be considered early, because it may take time to mobilize Use balloon tamponade following a vaginal may stop bleeding in many cases. services. When embolization is successful, the patient can rapidly recover without Prostaglandin F2 ’05 B-Lynch Copyright © α delivery and atonic postpartum hemorrhage, that is undergoing additional surgery. Embolization not only saves the life of the patient, Prostaglandin F2 requires refrigeration. It is Aortic Compression How it works Syntometrine/ergometrine α unresponsive to uterotonics, prior to interventional but also the uterus and adnexal organs, thus preserving fertility. administered intramuscularly, in a dose of 250 µg; the If bleeding is severe and if initial measures are not The NASG is a simple neoprene and Velcro device made of articulated Syntometrine requires refrigeration. It can be radiological procedures or surgical interventions, such maximum number of doses is eight (15 minutes apart) segments that are wrapped tightly around the legs, pelvis and abdomen. administered intramuscularly or intravenously, at a as the B-Lynch suture, uterine artery embolization or successful, then external aortic compression should be Stepwise Devascularization dose of 1 ampule (500 µg of ergometrine and 5 IU of (2 mg). It is contraindicated in women with asthma and considered. Successful aortic compression, is achieved It can be used to treat shock, resuscitate, stabilize and prevent further iliac artery ligation or hysterectomy being considered. The essential requirements are not simple and may not be available in every unit. There is a need for a competent syntocinon). Syntometrine is contraindicated in women cardiac disease. when the femoral pulse ceases and when blood pressure bleeding in women with obstetric hemorrhage. obstetric surgeon who is conversant and competent at pelvic gynecological procedures, and who has a working with hypertension and cardiac disease. It can be used during or after cesarean section and in in the lower limit is unrecordable; it may be of benefit as The NASG is light, flexible and comfortable for the wearer. It has been knowledge of the pelvic anatomy, including the vascular and neurological supply of the pelvic organs. Uterine artery and a woman with vaginal birth after previous cesarean section designed to allow perineal access so that examinations and vaginal Tranexamic Acid a temporary measure in the management of postpartum the infundibulopelvic vessels can be tied at the junction of the tube meeting the uterus without compromising ovarian with postpartum hemorrhage, after excluding rupture. hemorrhage whilst resuscitation and other management procedures can be performed without it being removed. Upon application a Carbetocin Tranexamic acid 1 –2 g hourly will reduce fibrinolysis and blood supply. plans are made. patient’s vital signs are often quickly restored and consciousness regained. Carbetocin is a synthetic oxytocin analogue that binds will stabilize the clot in the uterine vessels. It is given via to the same oxytocin receptors in the myometrium with the intravenous route, and is best used when the bleeding How to use Internal aortic How to apply the non-inflatable anti-shock garment (NASG) Internal Iliac Artery Ligation continues despite oxytocin and when prostaglandin has an affinity similar to that of oxytocin. Its main advantage Insert the balloon and instill warm sterile water/saline in compression can also Place the NASG under the women with the top edge at the level of her This could be used as a prophylactic or therapeutic operation. There is a need for a become necessary. over oxytocin is a four fold longer uterotonic activity increments of 50 ml while observing for bleeding from be used as a temporary lowest rib (on her side). competent obstetric surgeon who is conversant and competent at pelvic (up to 2 hours). This means there is no necessity for a the cervix. When bleeding stops instill an extra 50 ml. measure to control Close segment 1 (or 2, for short women) tightly around each ankle and gynecological procedures. continuous infusion. If bleeding continues despite the balloon herniating via make sure that when snapped, a sharp sound is heard. Recombinant Factor VIIa (rFVIIa) severe postpartum the cervix, the treatment is unlikely to be effective and Close segment 2 tightly around calf. Check for snap sound. Carbetocin 100 µg as an IV bolus over 1 minute instead rFVIIa is very expensive and requires refrigeration. It is hemorrhage due to Subtotal or Total Hysterectomy the balloon will be expelled. The next step should be Leave the knee free so that the leg can be bent. © Suellen Miller of continuous oxytocin infusion in elective cesarean used when uterine massage and uterotonic medications placenta percreta compression sutures. Close segment 3 tightly around the thigh. Check for snap sound. Hysterectomy is the best immediate option to save the hemorrhaging woman’s life section for the prevention of PPH has been shown (oxytocin, ergometrine, prostaglandins) have all failed to during cesarean Place segment 4 so it goes around the women with its lower edge at the level of her pubic bone. when uterine atony is unresponsive to uterotonics and where facilities for embolization to decrease the need for therapeutic uterotonics. For control postpartum hemorrhage. The recommended dose The fundal height should be marked and the height section. are not available and/or the obstetrician is not well versed with the technical aspects Place segment 5 with pressure ball directly over the umbilicus. women delivering vaginally with one risk factor for PPH, is 40–60 µg/kg, administered intravenously. monitored with vaginal bleeding, pulse, blood pressure of conservative surgical procedures or iliac artery ligation. Subtotal hysterectomy is carbetocin 100 µg IM decreases the need for uterine and urinary output to identify signs of continued NB. To view a video Close the NASG using segment 6. easy to perform, quick and is applicable in most cases of atonic uterine bleeding. Total massage to prevent PPH when compared with continuous In clinical practice this drug is used as a last resort bleeding. Prophylactic antibiotics and slow IV oxytocin demonstrating how to apply aortic compression visit Make sure the women can breathe normally with segment 6 in place. hysterectomy may be needed in cases of placenta previa, accreta and cases of uterine © Copyright B-Lynch ’05 infusion of oxytocin. because of its possible side effects and expense. infusion is advised. www.glowm.com NB. For a video demonstration of how to use a non-inflatable anti-shock garment visit www.glowm.com rupture involving the lower segment. STEP STEP This Leaflet BEFORE Prevention Immediate Action: and Wall Chart Call for HELP Check for: 1 Have someone available at all times to help manage Postpartum Hemorrhage 2

This leaflet and wall chart has been written and developed by Dr Mahantesh Karoshi, Incidence and Risk Factors Resuscitation Breathing Uterine Tone Placenta Professor Sir Sabaratnam Arulkumaran and Dr André Lalonde, and is based on The care-giver must ensure a safe environment; shake Assess breathing for 10 seconds by looking for chest After resuscitation, assessment of uterine tone is Inspection of the placenta after delivery must be Postpartum hemorrhage occurs in approximately be given to the mother after delivery of the A Comprehensive Textbook of Postpartum Hemorrhage (Second Edition), edited by the patient and shout. If there is no response, call for movements, listening for breath sounds and feeling for always the next step in the management of primary routine. If a portion of the placenta is missing, the 4% of vaginal deliveries, and it is estimated that placenta. Alternatively, 1 ampule of syntometrine Sir Sabaratnam Arulkumaran MD, PhD, FRCS, FRCOG, Mahantesh Karoshi MD, MRCOG, DCRCM, assistance and then return to the patient. the movement of air. If no breathing is detected, put out postpartum hemorrhage for which uterine atony is uterus should be explored and the fragment removed, it causes significant morbidity and 25% of all can be given intravenously. a cardiac arrest call and administer two rescue breaths. overwhelmingly the dominant cause. Uterine atony is particularly if postpartum hemorrhage continues. Louis G. Keith MD, PhD, FACOG, FRCOG, André B. Lalonde MD, FRCSC, FRCOG and maternal -related deaths. Speak to the patient at the very beginning of the suggested by the presence of a boggy soft uterus. If the Christopher B-Lynch FRCS, FRCOG Risk Factors for Postpartum Hemorrhage resuscitation process. Her verbal response gives several Circulation uterus is atonic, immediate attention must be given to Bimanual Uterine Compression Active management of labor incorporates three pieces of clinical information. To be able to speak, a mechanical massage by rubbing up for a contraction Odds If circulation is present but no breathing, continue Bimanual compression causes mechanical constriction

main interventions: administration of a uterotonic

P POST and by using pharmacological approaches to contract Risk factor ratio patient must have circulating oxygenated blood, a rescue breathing at a rate of 10 breaths per minute. of myometrial vessels and stimulates uterine This practical Guidelines for Immediate medication after delivery of the baby; cord clamping the uterus.

reasonable patent airway, a reasonable tidal volume, and Recheck the circulation every 10 breaths, taking no contractions. The steps of uterine massage are, first,

A

A Prolonged third stage of labor 7.6

Comprehensive Textbook of Textbook Comprehensive About the Book RT A Comprehensive Textbook of Action is based on material published in and cutting; and controlled traction on the umbilical a reasonable cerebral perfusion for her to comprehend more than 10 seconds each time. If the patient starts to insert a gloved hand into the vagina, and push up

Postpartum hemorrhage is the U

2nd Edition 2nd Pre-eclampsia 5.0

H RR MO principal cause of maternal mortality. HE M A Comprehensive Textbook of Postpartum cord while awaiting placental separation and and answer. against the body of the uterus, and, second, place the It is estimated that up to 250,000 This new edition updates the breathe on her own but remains unconscious, turn her information provided in the first POSTP women a year die as a result of the condition, and yet most of these deaths edition and also features over 30 new ART delivery. other hand above the uterine fundus on the abdomen chapters on cutting edge topics Mediolateral 4.7 into the recovery position and administer oxygen at a could be avoided. The knowledge UM Hemorrhage (Second Edition). The book, necessary to manage the condition including the mechanisms of action HEMORRH If the patient does not respond and appears lifeless, open effectively already exists, so that today of anti-shock garments, sublingual and compress the posterior uterine wall against the most women die from this condition misoprostol, vascular malformations as rate of 15 liters/minute. a cause of PPH and the role of Previous postpartum hemorrhage 3.5 in childbirth not because the An Essential Clinical ReferenceAGE which is available through the normal the airway, assess for breathing by watching the chest, knowledge to save them is unknown, ultrasound in therapeutic management. Good evidence shows that active management hand in the vagina. Bimanual compression also helps but rather because that knowledge The new edition also features the most

A for Effective Management has not been effectively transferred to recent protocol established for the treatment of postpartum hemorrhage. GE Twin pregnancy 3.3 listening and feeling and, if necessary, give two rescue medical professionals and others commercial channels in the Western World, of the third stage of labor provides a better to reduce bleeding, thus aiding rapid resuscitation. whose role is to care for mothers Communication & in childbirth. A special effort has been made to make 2nd Edition breaths and assess for signs of circulation (breathing the text practical and accessible to balance of benefits versus harms and should To be effective the compression should continue for This book is the only comprehensive many different levels of the medical is being provided free to selected physicians in Arrest of descent 2.9

textbook available on postpartum profession. The first section of special

André B. André movements and carotid pulse). Teamwork

hemorrhage. The first edition created chapters contains practical step-by-step Sir Sabaratnam Arulkumaran, Arulkumaran, Sabaratnam Sir

Edited by Edited 10 minutes that would allow the blood to clot in the algorithms designed to guide both Keith, G. Louis Karoshi, Mahantesh be practiced routinely to decrease the risk of a great impact when published in

2006 and has been very widely read clinicians and nursing staff on the most less-resourced countries. Soft-tissue lacerations 2.0 and used around the world, with appropriate sequence of procedures to Lalonde Wherever possible, have senior input from the obstetric, uterine vessels. some 15,000 copies distributed to follow when encountering emergency postpartum hemorrhage. Active management If there is no circulation, start chest compression as in the

less-resourced countries and with hemorrhaging after birth. This textbook, Christopher B-Lynch Christopher the text appearing in a number of which is extensively illustrated and and Asian ethnicity 1.7 anesthetic and midwifery professions. Ensure that the foreign language editions. referenced, contains contributions involves facilitation for the separation and delivery from over 120 experts from around The whole 650 page book is also available entirely cardiopulmonary resuscitation drill. the world. family is looked after and kept informed. Document of the placenta and enhances the effectiveness of Augmented labor 1.7 free of charge on the internet from the Global timings and interventions accurately. the uterine contractions to shorten the duration Forceps or vacuum delivery 1.7 Library of Women’s Medicine, where it may be Airway ISBN 978 of the third stage of labor and reduce the risk of -0-9552282- © Copyright Robert Demarest 7-8 Hispanic ethnicity 1.7 Place your hand on the patient’s forehead and gently tilt Logistics Edited by read or downloaded at will by Sir Sabaratnam Arulkumaran postpartum hemorrhage. Mahantesh Karoshi Midline episiotomy 1.6 the head back. At the same time, with your fingertips Recruit as many staff as possible. You will need an MD, MRCOG, DCRCM, MD, PhD, FRCS, FRCOG SAPIENS André B. PUBLISHING Lalonde Louis G. Keith , A4cover_aw2.indd MD, FRCSC, FRCOG anyone. To do so, please visit 2 and Christopher B-LynchMD, PhD, FACOG, FRCOG Oxytocin is the uterotonic agent of choice; it can be under the point of the patient’s chin, lift the chin individual responsible for each of the following: FRCS, FRCOG, D.Univ Adapted with permission from Combs CA, Murphy EL, Laros Trauma www.glowm.com administered as 10 units intramuscularly or as to open the airway. A jaw thrust may be required to recording events, management, communication and RK Jr. Factors associated with postpartum hemorrhage with At any time that bleeding persists in the presence of 5 units intravenously, and can safely and effectively vaginal birth. Obstet Gynecol 1991;77:73 facilitate this. runner/porter/transport. For further information, please a firmly contracted intact uterus, and after failure 01/08/2012 17:27 of initial measures to control , contact the Publishers – who are hemorrhage from lacerations of the cervix, vagina or publishing these materials on a not-for- uterus should be suspected. Adequate exposure of the Want to know more about the management of General principles of management profit basis and making them available vagina and cervix under good light and then repair form postpartum hemorrhage? Bleeding from the placental bed is arrested by the clotting of the vessels supplying the placental the keystone of the management of trauma. If uterine Abigail Bloomer free, on a selective basis, in loving bed and facilitated by uterine contractions –‘natural ligatures’. This is further enhanced by oxytocics rupture is suspected, then laparotomy and repair or © Copyright 1970–2001 If you would like to know detailed information about postpartum hemorrhage: hysterectomy become life-saving procedures. B-Lynch ’05 memory of their daughter Abigail Bloomer. 1. Read and/or download free of charge a 7-minute learning Module (principally designed for which keep the uterus contracted for a longer time, or by bimanual compression (maintained for midwives and other professional birth assistants) at www.glowm.com an adequate time) or by balloon or by compression sutures. Vessel ligation or embolization reduces 2. Read and/or download, free of charge, a 20-minute Masterclass Lecture (principally designed for the pressure and volume of flow. Medical and simple uterine conservation techniques need to be doctors and doctors in training) at www.glowm.com undertaken before coagulopathy sets in. Medications to promote clotting or to stabilize the clots can 3. Read and/or download, free of charge, the 650 page A Comprehensive Textbook of Postpartum be useful but should be used appropriately. Delay in intervening with the onset of coagulopathy gives Hemorrhage at www.glowm.com rise to the need for the use of blood and clotting factors as well as adequate fluid replacement.

The Foundation for the Global Library of Women’s Medicine Ltd. For detailed reading, consult A Comprehensive Textbook of Postpartum Hemorrhage, Section 7 and 32 Meadowbank, London NW3 3AY, UK  www.glowm.com  [email protected] Chapters 14, 15 and 66 For detailed reading, consult A Comprehensive Textbook of Postpartum Hemorrhage, Section 11 For detailed reading, consult A Comprehensive Textbook of Postpartum Hemorrhage, Chapter 51 and Appendix

STEP STEP STEP STEP Drug Therapy Balloon Seek Additional Hospital-based 3 for Management 4 Tamponade 5 Help 6 procedures

ergometrine as an intramuscular or diluted tamponade effect. Success is judged by no loss of blood from Where available, it should be the procedure of choice for Syntocinon/ intravenous bolus, followed by repeat dosage Prostaglandin F2α The Balloon Tamponade the cervix or seen through the drainage port. If the tamponade test fails, the next step B-Lynch Suture postpartum hemorrhage prior to surgical intervention, The third-line agent for use in the management oxytocin if no effect is observed after 5 minutes, and The balloon tamponade two-way catheter provides control of The B-Lynch suture aims to exert continuous vertical when other therapies have not achieved hemostasis. complemented by continuous intravenous of uterine atony unresponsive to syntocinon, All patients should be managed by close monitoring of vital With timely and appropriate use of uterotonic ergometrine or misoprostol is prostaglandin postpartum uterine bleeding in nearly 85% of cases and in the would be compression suture alone or a combination of compression on the uterine vascular system. Laparotomy, Embolization requires an obstetric department that is syntocinon infusion. Atony that is refractory signs, fluid input/output, fundal height and vaginal blood loss. therapy, the majority of women with uterine to these first-line oxytocics will warrant F2α, which has been shown to control others reduces the bleeding till the next step is undertaken. uterine exteriorization and an opened uterine cavity are well aware of its implications in postpartum uterine atony can avoid surgical intervention. hemorrhage in up to 86% of cases where other The balloon tamponade is especially feasible in a scenario of Continued oxytocin infusion may be necessary to keep the compression suture with a balloon (sandwich technique). necessary. Test for the potential efficacy of the B-Lynch prostaglandin therapy. means have failed. It is given intramuscularly hemorrhage and a proactive protocol providing easy Stimulation of uterine contraction is usually atonic postpartum hemorrhage following a vaginal delivery, uterus contracted over 12–24 hours. A prophylactic broad- suture by performing open bimanual compression to achieved, in the first instance, by external in a dose of 250 μg every 15 minutes, up to a access for the obstetricians to emergency care from the maximum of eight doses (2 mg). Intramuscular unresponsive to medical management and before interventional spectrum antibiotic should be administered. The mean time The compression suture devised by Christopher B-Lynch see whether the bleeding stops, before proceeding to uterine massage. Syntocinon acts rapidly, interventional radiology team. Carbetocin injection yields peak plasma concentrations for leaving the tamponade balloon ranges from 8 to 48 hours. with a latency period of <1 minute after radiological procedures or surgical interventions, such as the place the suture into the uterus. If the bleeding stops on Carbetocin is a synthetic oxytocin analogue at 15 minutes. It should be used with caution A gradual deflation of the balloon is advised to reduce the intravenous injection and 3–7 minutes after B-Lynch suture, or iliac artery ligation or hysterectomy are is well known and is described as the next step. applying such compression, there is a good chance that that binds to the same oxytocin receptors in patients with asthma, hypertension, cardiac potential risk of further bleeding. Tamponade procedures Stepwise Devascularization intramuscular injection. When syntocinon is in the myometrium with an affinity similar and pulmonary disease. Side-effects include considered. application of the B-Lynch suture will stop the bleeding. administered by a continuous intravenous to that of oxytocin. Its main advantage over nausea, vomiting, diarrhea, pyrexia and are simple, cheap, easy to use and effective measures that Essential requirements are an obstetrician competent infusion, the uterine response begins gradually oxytocin is a four fold longer uterotonic bronchospasm. It is light- and heat-sensitive The insertion technique is simple and consists of placing the should be considered for intractable postpartum hemorrhage, in pelvic gynecological procedures and an obstetric and reaches a steady state within 20–40 activity. This means there is no necessity for a and must be kept refrigerated at 4ºC. balloon portion of the Sengstaken, Rüsch or Bakri catheter especially when other options are not available. Procedure anesthetist, and provisions for close supervision minutes. The mode of action of oxytocin Home Delivery continuous infusion. (others have used a glove or condom tied to a catheter) The assistant performs compression and maintains it with postoperatively. The surgical approach starts with ligature involves stimulation of the upper uterine The guidelines of the Society of Obstetricians two hands during the placement of the suture by the of the uterine artery and its distribution to the uterus, segment to contract in a rhythmical fashion. Tranexamic Acid directly into the uterus, making sure that the entire balloon and Gynaecologists of Canada advise Alternative Owing to its short half-life (3 minutes), a Tranexamic acid is an antifibrinolytic agent is inserted past the cervical canal and internal os. A 60 ml surgeon. To perform the procedure, the operating surgeon either unilaterally or bilaterally, preferably as it emerges clinicians to use carbetocin 100 µg as an IV and is widely used in general surgery to reduce An alternative innovative approach from Bangladesh uses a continuous intravenous infusion is required in should be well accustomed with the steps, which can be from crossing over the ureter or as it approaches the bolus over 1 minute instead of continuous blood loss. A systematic review of randomized syringe or a giving set of a saline infusion can be used for sterile rubber catheter fitted with a condom as a tamponade order to maintain the uterus in a contracted achieved by regular practice during skills and drills courses uterine wall to penetrate and establish its divisions and oxytocin infusion in elective cesarean sections controlled trials of antifibrinolytic agents in inflating the balloon. The balloon is filled gradually and when balloon device. The sterile catheter is inserted within the state. Rapid intravenous bolus administration on dummies. the infundibulopelvic vessels before they enter the uterus. for the prevention of PPH and to decrease the elective surgery showed that tranexamic acid the bleeding stops emerging via the cervix, the method is condom and tied near the mouth of the condom with a silk  of undiluted oxytocin results in relaxation need for therapeutic uterotonics. reduced the risk of blood transfusion by 39%. successful and another 50 ml is introduced to make sure of vascular smooth muscle, which can cause Tranexamic acid can be offered as a treatment thread; the outer end of the catheter is connected to a saline severe hypotension. Therefore, it is best given Carbetocin has the advantage of ease of for PPH either (i) when two successive it is effective. It is unusual for more than 500 ml to be set. After placement in the uterus, the condom is inflated Other Procedures Internal Iliac Artery Ligation administration and its potentially lower Nursing Station or Health Unit by intravenous infusion or the intramuscular uterotonics have failed to stop the bleeding required and if that is the case, exploration by laparotomy with 250–500 ml normal saline according to need, and the Conditions indicating ligation are postpartum hemorrhage overall cost, together with its improved or (ii) if it is thought that the bleeding may Square Compression Sutures route. Syntocinon is stable at temperatures may be needed and a compression suture as the next step. outer end of the catheter is folded and tied with thread after due to atonic uterus refractory to other measures, up to 25ºC, but refrigeration prolongs its efficacy may provide the basis for the wider be partly due to trauma. A Cochrane Review Multiple square sutures are used to cover the whole body If there is continued bleeding with this volume or if the bleeding has stopped. To keep the balloon in situ, the vaginal shelf-life. use of carbetocin in the prevention of PPH reported that a dose of 0.5–1 g intravenously of the uterus and may be useful in cases of placenta abruptio placentae with uterine atony, abdominal especially in low resource areas. was effective in reducing postpartum balloon herniates, compression suture should be considered. cavity is packed with roller gauze. This method represents a The preferred storage of oxytocin is refrigeration previa (ensure a drainage portal is left). Check that the pregnancy with pelvic implantation of the placenta and hemorrhage after vaginal birth and cesarean Gentle traction on the balloon shaft ensures proper contact cheap, simple and quick intervention, which is invaluable in but it may be stored in temperatures up to section with minimal side-effects. compression sutures have worked by observing blood loss placenta accreta. Therapeutic indications include: before 30ºC for up to 3 months without significant between the balloon and the tissue surface and enhances the resource-poor countries.  or after hysterectomy for postpartum hemorrhage; Misoprostol vaginally before closing the abdomen. Suture through and loss of potency (WHO 1993). Misoprostol is a synthetic analogue of through with a straight 10-cm needle. continuous bleeding from the broad ligament base; prostaglandin E1. It can be given orally, Recombinant Factor Pelvic Packing – Achieving hemostasis in difficult cases when standard surgical methods are not District or Regional Hospital profuse bleeding from the pelvic side-wall or the angle of vaginally or rectally. Current evidence VIIa (rFVIIa) the vagina; diffuse bleeding without a clearly identifiable Syntometrine/ suggests 400–600 µg of powdered working (a “second line of defence”) Patients who develop massive, life threatening Uterine Compression vascular bed; ruptured uterus in which the uterine artery misoprostol sublingually may help to achieve postpartum hemorrhage often exhibit a In cases where hemodynamic stability Pelvic packing can then be applied. normalized as soon as possible in order to ergometrine peak serum levels quickly, compared to Sutures – Vertical may be torn at its origin from the internal iliac artery; and Syntometrine causes sustained tonic uterine combination of ‘coagulopathic’ diffuse bleeding is not achieved either during cesarean The pouch of Douglas and the anterior stabilize the intrinsic hemostatic system. 3 minutes for oxytocin and may be more in addition to ‘surgical bleeding’. Whereas These are an alternative to the B-Lynch technique if no where extensive lacerations of the cervix have occurred contraction. It stimulates contraction of both section or after cesarean hysterectomy vesical space should be packed using When a normal body temperature has effective than rectal or oral route. Common bleeding from larger vessels may be controlled lower segment cesarean incision is present. They may be following difficult instrumental delivery. the upper and lower uterine segments in a – or in cases involving complicated standard surgical (medium or large) been achieved a second attempt at side-effects are shivering and pyrexia. (NB by surgeons using a variety of operations,  placed without opening the uterus, using a straight 10-cm tetanic manner. Intramuscular injection of Repeated doses of misoprostol are not instrumental delivery – pelvic packing gauzes and the fascia should then be hemorrhage control by changing the the ability to control diffuse bleeding is needle. Ensure downward bladder retraction and place two a 500 μg dose results in an onset of action recommended). Misoprostol is recommended limited and, in many cases, not feasible. Thus, may be useful. closed. Afterwards the patient should be packing should be considered. Hysterectomy after 2–5 minutes. The clinical effect of to four vertical sutures. Check that the compression sutures for its low cost and ease of administration, administration of hemostatic drugs that can Before proceeding a careful check transferred to an intensive care unit for Once the hemodynamics are stabilized, If necessary, transfer to Emergency peripartum hysterectomy is the best option syntometrine persists for approximately and is a powerful uterotonic with an control the coagulopathic component of blood have worked by observing blood loss per vaginum before should be made for any obvious arterial further stabilization. the packing should normally be left in when uterine atony is unresponsive to oxytocics and 3 hours. The co-administration of excellent safety profile and long shelf-life. loss may reduce mortality and morbidity in closing the abdomen. ergometrine and syntocinon results in a In situations where appropriate methods such patients. bleeding which could be readily accessed If the bleeding still continues, place for 24–48 hours. During a “second prostaglandins and where facilities for embolization complementary effect, with syntocinon exist to diagnose quantity of blood loss and  rFVIIa has a special role in patients with and controlled by clamping, by ligature, an angiography, combined with look” operation it is usual to observe a Tertiary (University) Hospital are not available and/or the obstetrician is not versed achieving an immediate response and where are attended by traditional HELLP syndrome and in patients with or by tying the artery. The effectiveness embolization, can be performed. If active significant improvement or complete in instances where full therapeutic measures such as blood bank facilities, surgical expertise, Uterine Artery Embolization with conservative surgical procedures. Uterine rupture ergometrine a more sustained action. birth attendants who are trained to use disseminated intravascular coagulopathy cessation of the bleeding. If there is any of the tamponade should be re-checked bleeding persists and the need for blood operating theater facilities, or embolization are not available or where there are delays in Embolization is a highly feasible, safe and beneficial secondary to obstructed labor and previous cesarean Contraindications include cardiac disease, misoprostol, its use results in a highly who are experiencing postpartum and all identifiable bleeding controlled transfusion becomes apparent, the remaining bleeding, it may be controlled hemorrhage. receiving these therapies or for intensive care monitoring in a patient who continues to bleed. procedure, possibly precluding further laparotomy section may be indications. If the rupture is extensive hypertension and pre-eclampsia. First- significant reduction in the number of by direct surgical means where possible. patient’s body temperature should be by local surgical hemostasis. line treatment of uterine atony, therefore, women who need to be referred to hospital  The recommended dose is 40–60 μg/kg and hysterectomy. If successful, it not only saves the and hemorrhage cannot be contained by suture of the involves administration of oxytocin or for further treatment. administered intravenously. patient’s life, but also the uterus and adnexal organs. ruptured area, then hysterectomy may be necessary. For detailed reading, consult A Comprehensive Textbook of Postpartum Hemorrhage, Chapters 45–49 and 54 For detailed reading, consult A Comprehensive Textbook of Postpartum Hemorrhage, Chapters 38 and 39 For detailed reading, consult A Comprehensive Textbook of Postpartum Hemorrhage, Sections 6 and 8, and Chapters 14, 15 and 40 For detailed reading, consult A Comprehensive Textbook of Postpartum Hemorrhage, Chapters 2, 51–53 and 55