1. Communicate the emergency and alert all necessary staff. 2. Resuscitate the patient with oxygen, IV fluids, and blood products to restore circulation and oxygen-carrying capacity. 3. Continuously monitor vital signs and investigate laboratory values every 15 minutes to guide resuscitation efforts. Stop the bleeding through techniques like bimanual compression, uterotonic drugs, balloon tamponade, or surgical interventions if needed.

1. The Use of Algorithms &
Emergency Boxes
in Obstetric Emergencies
Wafaa B. Basta
MRCOG
Consultant Obstetrics & Gynaecology MTH
ERC member

2. Obstetric Haemorrhage
• Is the major cause of maternal mortality
globally.
• Substandard management identified as a
contributor for maternal mortality in UK in
80% of the cases.
• Is the major cause of mortality in Egypt
,according to the last Egyptian Maternal
Mortality Report in 2001.

3. PPH
• WHO: EBL in NVD > 500 ml
• In CS >1000 ml ?
• PPH can be
1. Minor (500–1000 ml)
2. Major (more than 1000 ml).
a) moderate (1000–2000 ml)
b) severe (more than 2000 ml).
Consideration of rapidity of loss , underlying anaemia,
body weight,....
So, Hemodynamic compromise is important guide .

4. PPH
Prevention
Early Identification
Prompt and appropriate interventions

5. Early Identification
CEMACH 2007
In many cases in this report, the early warning
signs of impending maternal collapse went
unrecognized.

6. Early Identification
Blood Loss BP syst Symptoms Signs
500-1000 mls
(10-15%)
Normal Palpitation ,
dizziness
Tachycardia
1000-1500 mls
(15-25%)
80-100 mmHg weakness Tachypnoea ,
sweating, Postural
hypotension
1500-2000 mls
(25-30%)
70-80 mmHg Restlessness Marked
Tachycardia, Pallor,
Oligurea
2000-3000 mls
(35-45%)
50-70 mmHg Collapse Marked
Tachycardia, Pallor,
cold clammy skin,
Peripheral cyanosis
,Air Hunger, Anurea
Confusion,
unconsciousness,
collapse

7. Early Warning Chart
(CEMACH 2003-5)

8. Management of PPH
Communicate Resuscitate
Monitor &
Investigate
Stop
the Bleeding

9. Lack of communication
=
Main cause of substandard care.

10. Work in a team
Do all needed steps
In the proper sequence of the steps

11. Competent Emergency Team
Knowledge
Skills
Attitude
Labor Ward drills

12. 1.Communicate
alert all staff
• Senior Obstetrician.
• Senior Nurse.
• Blood Bank.
• Anaesthetic Staff.
• Haematologist.
• Porters.
• PPH emergency Box.
• Member of the team to record the events.

15. PPH Box
• Algorithm
• 2 Green Canula (18), 2Grey (16)
• 4 Ringer
• 3Haemagel
• 2 IV lines
• Urinary Catheters: Fooly’s 20, Nelyton & bag
• Blood Sampling Tubes: 2violet,1 red, 1 blue
• Syringes : 2(20ml),2(10ml),4(5ml) ,4(3ml)
• Gloves: sterile& disposable
• Adhesive Tape
• Umbilical clamp
• Misoprostol 5 Tab
• NB: Syntocinon & Methergine are in the fridge

17. Management of PPH
Communicate Resuscitate
Monitor &
Investigate
Stop
the Bleeding

18. 2. Resuscitate
Resuscitation
• Shake the patient and shout.
• If there is no response, call for assistance and then return to the patient.
• Speak to the patient ,if responds , she must have a reasonable patent
airway, a reasonable tidal volume, and a reasonable cerebral perfusion for
her to comprehend and answer.
• If the patient does not respond , open the airway, assess for breathing by
watching the chest, listening and feeling and, if necessary, give two rescue
breaths and assess for signs of circulation (swallowing and breathing
movements and carotid pulse).
• If there is no circulation, start chest compression as in the
cardiopulmonary resuscitation drill .

19. 2. Resuscitate
Airway
Gently tilt the head back.
Lift the chin to open the airway.
Breathing
Assess breathing for 10 seconds by looking for chest movements, listening for
breath sounds and feeling for the movement of air.
If no breathing is detected, put out a cardiac arrest call and administer two
rescue breaths.
Circulation
If circulation is present but no breathing, continue rescue breathing at a rate
of 10 breaths per minute. Recheck the circulation every 10 breaths, taking
no more than 10 seconds each time.
If the patient starts to breathe on her own but remains unconscious, turn her
into the recovery position and administer oxygen at a rate of 15
liters/minute.

20. 2. Resuscitate
• oxygen 10-15 L/ min.
• Position flat.
• 14 G IV line x2
• 20 ml of blood sample should be taken for FBC, urea &
electrolytes, coagulation profile &cross match 4 unites.
Restore circulation
• Crystalloid max 2L
• Colloid max 1.5L
Improve O2 carrying capacity
• Blood (Warm, Rapid , No Filter)

22. What blood components can be used ?

23. Fluid therapy & blood product
transfusion
Crystalloid
Colloid
Up to 2 litres of Hartmann’s solution (warm)
Up to 1.5 litres until blood arrives (warm)
Blood cross-matched If cross-matched blood still unavailable, give
uncrossed-matched group specific blood or O RhD
negative blood
Fresh frozen plasma 4 units for every 6 units of red cells or PT/a
PTTT>1.5 normal (12-15ml/kg or total 1litre)
Platelet concentrate If platelet count <50 .109
Cryoprecipitate If fibrinogen <1g/l (up to 10 unites =two packs)

24. The best equipment
available should be
used to achieve
RAPID WARMED
infusion of fluids

25. The main therapeutic goals
• Haemoglobin >8g/dl
• Platelet count>75.109
• Prothrombin<1.5.mean control
• Activated prothrombin time <1.5.mean
control
• Fibrinogin>1.0 g/dl

26. Management of PPH
Communicate Resuscitate
Monitor &
Investigate
Stop
the Bleeding

27. 3. Monitor & Investigate
• Blood loss.
• Pulse , BP, RR
• O2 saturation
• UOP
• Invasive monitoring: Arterial / CVP
• Hb%, HCt, platlet
• PT,PTT, Fibrinogen
To be done & documented every 15 minutes in the
initial stage. (early warning chart)

28. Management of PPH
Communicate Resuscitate
Monitor &
Investigate
Stop
the Bleeding

29. 4.Stop The Bleeding
• Asses uterine tone
• Bimanual compression.
• Drug therapy (utero-tonics)
• Exclude trauma
• Balloon tamponade
• Surgical intervention:
– Bilat ligation of uterine arteries
– Brace sutures
– Stepwise devascularization
– Bilat IIAL
– Selective arterial embolisation
– Hysterectomy

30. 4.Stop The Bleeding
Assessment of uterine tone & Placental inspection
Empty bladder
If atony
Rub up for a contraction by Mechanical massage and uterotonic drugs
If missing placental portions
Explorations & fragments removed
If trauma is suspected
( bleeding persists in the presence of a firmly contracted intact uterus,
and failures of initial measures to control postpartum bleeding)
Adequate exposure &repair of the vagina and cervix under good light .
If uterine rupture is suspected
laparotomy and repair or hysterectomy

31. Bimanual Uterine Compression
Mechanical constriction of myometrial vessels
Stimulates uterine contractions.
Helps to reduce bleeding
Aiding rapid resuscitation

32. Drug Therapy
• Syntocinon 5 units by slow IV (may be
repeated)/ 40 units in 500 ml ringer at 125/h.
• Ergometrin 0.5mg by slow IV or IM
• Misoprostol rectal 600-1000 ug
• Caboprost 0.25 mg by IM repeated 15 min
,maximum 8 doses (CI in asthma)

33. Drug Therapy
Oxytocin Ergometrine Misoprostol
Acts 2-3 min, lasts 1 hour Acts 6-7 min ,lasts 1-3
hours
Acts in 6-20 min, lasts 2
hours
safe Contraindicated in
hypertension & cardiac
safe
inexpensive inexpensive inexpensive
Minimal side effects Nausea , vomiting Shivering & fever
Cold storage Cold storage No Cold storage

34. WHO Recomendation for doses
Oxytocin Ergomtrine
Dose & route IV 20 U in 1L IV
fluids at 60
drop/min
IM or IV slowly 0.2
mg
Continuing dose IV 20 U in 1L IV
fluids at 40
drop/min
Repeat 0.2 mg IM
after 15 min
If required 0.2 IM
or IV slowly every 4
hours
Maximum dose Not more than 3L
of IV fluids
containing Oxytocin
5 doses (total 1.0
mg)
CI Not as IV bolus PE, HT, heart

35. PABAL 100 micrograms/ml
• Carbetocin 100 micrograms/ml.
• Oxytocic activity: approximately 50 IU of oxytocin/ampoule
• PABAL is indicated for the prevention of uterine atony
following delivery of the infant by Caesarean section under
epidural or spinal anaesthesia.
• PABAL must be administered slowly, over 1 minute only
after delivery of the infant by Caesarean section. It should
be given as soon as possible after delivery, preferably
before removal of the placenta.
• PABAL is intended for single use only. No further doses of
carbetocin should be administered.

36. Drug Therapy
Recombinant Factor VIIa (rFVIIa)
• Massive hemorrhage : a combination of
‘coagulopathic’ diffuse bleeding in addition to
‘surgical bleeding’.
• rFVIIa has a special role in patients with HELLP
syndrome and in patients with disseminated
intravascular coagulopathy who are experiencing
postpartum hemorrhage.
The recommended dose is 40–60 μg/kg
administered intravenously.

37. Drug Therapy
Tranexamic acid for TTT of PPH
International randomized, double blind placebo controlled trial

38. Balloon Tamponade
The insertion technique :
• place the balloon portion of the catheter directly into the uterus.
• make sure that the entire balloon (500 ml capacity) is inserted past the
cervical canal and internal os.
• A 60 ml syringe can be used for inflating the balloon.
• Success is judged by a declining loss of blood from the cervix and the
drainage port.
• monitor vital signs, fluid input/output, fundal height and vaginal blood
loss.
• Continued oxytocin infusion over 12–24 hours.
• prophylactic broad-spectrum antibiotic.
• from 8 to 48 hours.
• A gradual deflation .

39. The "tamponade test" in the management of massive postpartum
hemorrhage using
Sungstaken-Blakemore Tube
Condous et el Obstet Gynecol. 2003 Apr;101(4):767-72

40. Rusch hydrostatic balloon catheter

41. Bakri
Tamponade Balloon
1. Y. N. Bakri, A. Amri, F. Abdul Jabbar: “Tamponade-balloon for
obstetrical bleeding,” International Journal of Gynecology and
Obstetrics, 74 (2001), 139-142.

42. Balloon Tamponade Alternative
From Bangladesh uses a sterile rubber catheter fitted
with a condom as a tamponade balloon device
The sterile catheter is inserted within the condom and
tied near the mouth of the condom with a silk thread;
the outer end of the catheter is connected to a saline
set.
After placement in the uterus, the condom is inflated
with 250–500 ml normal saline according to need, and
the outer end of the catheter is folded and tied with
thread after bleeding has stopped.
To keep the balloon in situ, the vaginal cavity is packed
with roller gauze.

46. selective arterial balloon
catheterization
Where available, it
should be the
procedure of choice for
postpartum
hemorrhage prior to
surgical intervention.

47. B-Lynch Sutures
Test for the potential efficacy of the B-Lynch suture by performing open
bimanual compression to see whether the bleeding stops, before
proceeding to place the suture into the uterus.
If the bleeding stops on applying such compression, there is a good chance
that application of the B-Lynch suture will stop the bleeding.
The assistant performs compression and maintains it with two hands during
the placement of the suture by the surgeon.

51. Other Brace Sutures
Square Compression Sutures
Multiple square sutures are used to cover the whole body of the uterus and may be
useful in cases of placenta previa (make sure to leave a drainage portal). Check
that the compression sutures have worked by observing blood loss vaginally
before closing the abdomen. Suture through and through with a straight 10-cm
needle.
Uterine Compression Sutures – Vertical
These are an alternative to the B-Lynch technique if no lower segment Cesarean
incision is present. They may be placed without opening the uterus, using a
straight 10-cm needle. Ensure downward bladder retraction and place two to four
vertical sutures. Check that the compression sutures have worked by observing
blood loss per vaginum before closing the abdomen.

52. Stepwise Uterine Devascularization
The surgical approach
starts with ligature of
the uterine artery and
its distribution to
the uterus, either
unilaterally or
bilaterally, preferably as
it emerges from
crossing over
the ureter or as it
approaches the uterine
wall to penetrate and
establish its divisions
and the infundibulo
pelvic vessels before it
enters the uterus.

53. Internal Iliac Artery Ligation
Conditions indicating ligation are;
postpartum hemorrhage due to atonic uterus refractory to other
measures,
abruptio placentae with uterine atony,
abdominal pregnancy with pelvic implantation of the placenta
placenta accreta.
Therapeutic indications
before or after hysterectomy for PPH;
continuous bleeding from the broad ligament base;
profuse bleeding from the pelvic side-wall or the angle of the
vagina;
diffuse bleeding without a clearly identifiable vascular bed;
ruptured uterus in which the uterine artery may be torn at its
origin from the internal iliac artery;
and where extensive lacerations of the cervix have occurred
following difficult instrumental delivery.

54. Hystrectomy
Emergency peripartum hysterectomy is the best
option when uterine atony unresponsive to
oxytocics and prostaglandins and where facilities
for embolization are not available and/or the
obstetrician is not versed with conservative
surgical procedures.
Uterine rupture secondary to obstructed labor and
previous Cesarean section may be indications. If
the rupture is extensive and hemorrhage cannot
be contained by suture of the ruptured area.

55. Work in a team
Do all needed steps
In the proper sequence of the steps