Maternal Collapse in labour ward

Dr . J. Edward Johnson. M.D., D.C.H. Asst. Professor , Dept. of Anaesthesiology, KGMCH.

Case Summary: 1
2 a.m.

Mrs. Everybody’s Patient

A 30 year old woman, 37 weeks pregnant with TWINS arrives at the hospital Cervix: 6 cm dilated. Patient is in severe pain. Labor is progressing rapidly Epidural block: 15 ml 0.125% bupivacaine + fentanyl 75 µg 15 minutes later - patient is still in severe pain 12 ml 0.25% bupivacaine given in two increments Patient is comfortable. You go to bed and fall into a deep sleep…...

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Case Summary: 1 Cont…….
3 a.m.

Obstetrician and anesthesiologist called “stat” to labor room Membranes ruptured spontaneously 10 min ago 3 min ago, the patient complained of difficulty breathing and lost consciousness Fetal heart rate: 90 beats/min Vaginal bleeding Patient cyanotic Maternal BP and Pulse not obtainable

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.Case Summary:1 Cont….    Patient mask ventilated with Ambu bag and O2 No improvement… You start CPR with the aid of the anesthesiologist 3. 3.03 a.m.m.  Patient is intubated .07 a.she aspirates gastric contents!  ASYSTOLE diagnosed .

• • • All IV lines displaced during CPR Epinephrine given via endotracheal tube IVs replaced with difficulty No maternal Pulse or BP detected FHR: 50-60 beats/min Cervix 8 cm dilated Patient transported to OT while closed chest 3.m. • • massage (CPR) continues Cesarean Section started .m.10 a.m.17 a.13 a.Case Summary:1 Cont…. 3. • • • 3.

Delivery of male infants: A: Apgar: 0. 1.Case Summary:1 Cont…. 4 (at 1. 0. 0 Delivery occurred 23 minutes after start of CPR .m.23 a. and 10 minutes) B: Apgar: 0. 3. 5.

3.  Maternal heart rate returns   BP 100/70.m.25 a.Case Summary: 1 Cont….m. • • Mother unconscious in ICU Coagulopathy (DIC) resolving .00 p. Pulse 130 Significant bleeding 22.30 a.m. 3.

Possible Causes of Cardiac Arrest • • • Amniotic fluid embolism Pulmonary embolism Hemorrhage (including ruptured uterus) Myocardial infarction. cardiomyopathy High spinal (or sub-dural) anesthesia Spinal opioid respiratory depression • • • .

Mrs. 70 kg Pre-operative: BP = 98/60. patient sitting Bupivacaine 12 mg + Fentanyl 10 µg .1500 ml crystalloid solution Uncomplicated spinal at L3/4. Everybody’s Patient 2 “Let’s Do an Elective C/Section…” • • • • • • Healthy 30 y old primigravida with twins for elective C/S (breech/Vx) 5 ft 4 inches tall. Pulse 52 Fluid preload .

” Poor hand strength . nauseated .Continue d: • • • • • • Patient is placed supine.patient cannot raise arm Patient is anxious. left uterine displacement Block T4 bilaterally (3 min after spinal) “I don’t feel well… My hands are numb” “I can’t breathe. diaphoretic.

Events after Spinal Block for Cesarean Section 180 160 140 120 100 80 60 40 20 0 Hands numb Nausea Chest Pain Dyspnea Syst BP Diast BP Pulse SPO2 Cardiac Arrest! Phenylephrine Ephedrine (mg): 5 5 10 10 10 10 10 10 100 µg 0 2 Time after spinal block (min) 4 6 8 10 12 14 16 .

5 • Babies to Intensive Care. 4. 6. 7 B: 3. severely acidotic .Cardiac Arrest during Spinal for Cesarean Section Cont…… • • • CPR / ACLS started Immediate Cesarean Section performed Delivery: 5 min after arrest occurred Apgar scores: A: 5.

intubated Mother has residual neurologic deficit.Post-Delivery Course Cont…… • • • • • • Mother responds to epinephrine: 1 mg x 3 after 10 minutes of resuscitation (5 min after delivery) BP 160/110. memory and concentration significantly impaired Unable to work or care for babies Babies appear normal at 2 years of age . P 140 To ICU.

“This wILL never happen to my patient !” Your attitude .

Dec 2004 .

ore Dec 2004 we were not aware of Tsunami thought it will never happen to us were not prepared death toll stood at 169. .752 with 127.294 people listed as missing.

This wILL never happen to my patient ! So denial won’t help us Be prepared for any catastrophes .

Maternal Collapse in labour ward .

DISCUSSION .

Embolism Amniotic Fluid Embolism Pre-eclampsia/eclampsia Cardiac (Valvular HD) Syncope Sepsis Respiratory .CAUSES OF MATERNAL COLLAPSE • • • • • • • • Haemorrhage (APH. PPH) Pul.

Causes of Collapse • 4 H’s: Hypoxia Hypovolaemia (bleeding/block) Hypothermia Hypo/hyperkalaemia (metabolic) • 4 T’s: Thromboembolic (PE or AFE) Toxic/therapeutic (local anaesthetic) Tension pneumothorax Tamponnade • Eclampsia .

Leading causes of Direct Deaths (Mortality rates/Million Maternities) .

Postpartum Hemorrhage

“Obstetrics is Bloody Business”*
*Cunningham, et. al: Williams Obstetrics, 21st ed.,

DIAGNOSIS OF ETIOLOGY

Postpartum Hemorrhage .

Diagnosis of Causes Postpartum Hemorrhage  Retained placenta Placenta Accreta  Uterine atony  Vaginal and cervical laceration  DIC. AFE  Factor disorder  Uterine rupture / Uterine inversion  .

0 3.005 .038 .02 .0 4.Lab Diagnosis The Decrease of Fibrinogen is an Early Predictor of the Severity of Postpartum Haemorrhage Severe group n=50 Platelets(10² L-1) PT (%) INR APTT ratio Fibrinogen (g L-1) Factor II (%) Factor V (%) D-Dimer (μg mL-1) Antithrombin activity (%) Protein C antigen (%) Euglobulin lysis time (% <180 min) 173 81 1.02 .3 83 72 9 72 69 26 Nonsevere group n=78 181 88 1.005 .4 93 90 6 79 75 19 .0001 .10 1.007 .16 1.004 .05 <.

MANAGEMENT RESUSITATION OF Haemorrhagic Shock Cardiac Arrest .

RESUSITATION Haemorrhagic Shock .

 1997 .Classification of Haemorrhage Class Acute Blood Loss % Lost 1 2 3 4 900cc 1200-1500cc 1800-2100cc 2400cc 15 20-25 30-35 40 Baker R. Obstet Gynecol Annu.

Less blood volume . Subjective & Inaccurate) Underestimation is likely Clinical picture -Misleading Our Mothers-Malnourished. Small built.ASSESSMENT OF BLOOD LOSS AFTER DELIVERY • • • • • Difficult Mostly Visual estimation (So. Anaemic.

weakness pallor. confusion anuria. thirst.SYMPTOMS & SIGNS Blood loss Systolic BP Signs & Symptoms (% B Vol) ( mm of Hg) 10-15 15-30 30-40 40+ Normal slight fall 60-80 40-60 postural hypotension ↑PR. coma. death Recognition is late .>30% B Vol loss .oliguria. air hunger.

Modified Early Warning Scoring System (MEWS) MEWS calculated from 5 physiological variables • • • • • Mental response Pulse rate Systolic BP Respiratory rate Temperature .

• Respiratory rate ≥35 breaths per minute or a hea rate ≥140 beats per minute. • Heart rate of ≥110 or <55 beats per minute. • Not fully alert and orientated. • Urine output over the last four hours of <100ml. • Oxygen saturation of <90 per cent. .Modified Early Warning Scoring System (MEWS) The senior nurse would call the doctor for three or more of following criteria: the • Respiratory rate of ≥25 or <10 breaths per minut • Arterial systolic blood pressure of <90mmHg.

but you have to remember that studies show the half-life of vigilance is about 15 minutes.Vigilance is great. Author unknown .

DO NOT UNDERESTIMATE BLOOD LOSS Clinical Features of System CNS Cardiac Shock Shock Early Altered mental states Tachycardia Orthostatic hypotension Late Shock Obtunded Cardiac failure Arrhythmias Hypotension Renal Respiratory Hepatic Gastrointestin al Hematological Metabolic Oliguria Tachypnea Anuria Tachypnea Respiratory failure No change No change Anemia None Liver failure Mucosal bleeding Coagulopathy Acidosis Hypocalcemia Hypomagnesemia .

5 mL/kg/hr Normal mental status • • Eliminate the source of hemorrhage Avoid overzealous volume replacement that may contribute to pulmonary edema .Goals of Therapy • Maintain the following: Systolic pressure >90mm Hg Urine output >0.

CBC. PT/PTT. platelets.administer wide open Sample blood. T&C and order 4u PRBCs Monitor I&O.Management of Obstetrical Hemorrhage       Oxygen by mask 10 liter/min. . – to keep O2 saturation > 94% 1st IV Line: Ringer Lactate with Pitocin 2040 units at 1000 ml/ 30 minutes 2nd IV Line: 18 G IV: warm RL . Anesthesiologist. fibrinogen. urinary Foley catheter Get help -Senior Obstetrician.

rupture  Emperic transfusion -2 u PRBC. hematomas. dextran) Anticipate Disseminated Intravascular Coagulapathy (DIC) Verify complete removal of placenta. -Uncrossed (O neg.Management of Obstetrical Hemorrhage      LR or NS replaces blood loss at 3:1 Volume expander 1:1 (albumin.) PRBC – For emergency . may need ultrasound Inspect for bleeding -episiotomy. inversion. laceration. hetastarch. FFP 1-2 u/4-5 u PRBC -Cryo 10 u.

Blood Component Therapy Random Donor Platelets Single Donor Platelets Red Cells Leucocyte-Reduced Red Cells Irradiated Blood Washed Blood Frozen Cellular Components Cryoprecipitated AHF Fresh Frozen Plasma Fibrinogen Concentrate Liquid Plasma Plasma Derivatives .

ABO + Rh compatible Single donor Expire 4 h after pooling Expire 4 h after released 3-5 day survival in vivo (in DIC) .Platelets Random Donor Apheresis Pooled 4-8 units.

(contains all coag factors) PT. VW) Fibrinogen 5 mgldL . Fibrinogen.5 FFP Warm Spin Cryoprecipitate (VIII. XIII. PTT > 50% increase or INR > 1.

< 100.4u FFP – INR > 2. < 50.5 . count.000 – 1u plateletpheresis – Platelet.6u FFP Cryoprecipitate ( 1u/ 10Kg ) – Fibrinogen < 100 mg/dl – 10u cryo – Fibrinogen < 50 mg/dl – 20u cryo Platelets – Platelet.5 .Blood Component Therapy    Fresh Frozen Plasma – INR > 1.5 . count.000 – 2u plateletpheresis .2u FFP – INR 2-2.

count by 25.Blood Component Therapy Blood Comp Contents Volume (ml) 300 250 Effect Packed RBCs Platelets RBC. Factor V111. VonWillebrand F. clotting factors. Plasma Platelets. Fibronectin 40 Inc. Fibrinogen 10 mg/dl . plasma 250 Inc. Hgb by 1 g/dl Inc. antithrombin III.000 FFP Fibrinogen. X111. Plasma Inc. Fibrinogen 10 mg/dl Cryoprecipita te Fibrinogen.

5 times control Repeat labs as needed – every 30 minutes .Target Values • • • • • • • Maintain systolic BP>90 mmHg Maintain urine output > 0.000/ul Fibrinogen > 100 mg/dl PT/PTT < 1.5 ml per kg per hour Hct > 21% Platelets > 50.

Blood Component Replacement Cost COSTS Whole Blood RBC Platelets FFP Cryoprecipitate UNIT Rs 850 Rs 850 Rs 900 Rs 850 Not available Time to get 1Hr 1Hr 2 Hrs 1Hr .

Management of Major Obstetric  Haemorrhage  Recombinant factor VIIa  (rFVIIa) .

. rFVIIa Xa X Here it enhances localized thrombin generation and the formation of a Prothrombin stable fibrinbased clot. rFVII a Fibrin The fibrin clots formed in the presence of of a high thrombin concentration have a different architecture that is stronger and more resistant to degradation by fibrinolytic enzymes. Fibrinogen Thromb in Va In pharmacological doses rFVIIa binds directly to the activated platelet surface. where tissue factor (TF) is expressed and activated platelets aggregate.the site of vascular injury.

-non-acidotic milieu -adequate levels of fibrinogen (> 1.000) • A relatively early itervention to control PPH appears to be crucial for the success of rVIIa .Recombinant factor VIIa • It is not licensed for use in obstetric haemorrhage and there have been no randomised contolled trials for its use in this situation • The dose is approximately 90μg/kg. • Its efficiacy is dependent on -normothermia.5gr) -platelets (> 50.0-1.

Management of Major Obstetric  Haemorrhage ­ rFVIIa • rFVIIa will not replace ligatures in controlling bleeding from damaged or torn vessels. . • You should make your best efforts to correct acidosis and hypothermia. • To be effective there must be adequate circulation delivering platelets and fibrinogen to the site of bleeding.

TREAT THE ETIOLOGY OF PPH .

Anesthesiologist. .Blood Bank      Correction of hypovolaemia Ascertain origin of bleeding Ensure uterine contraction Surgical management Management of special .MANAGEMENT OF PPH  TEAM .Haematologist and .Obstetrician. .

Massive Obstetric Haemorrhage Treatment  Medical  Surgical  Blood Component Therapy  Post Treatment Care .

Cryoprecipitate. X Matched) Coagulation Support (FFP.Ergotamine.Colloid) Blood (O –tive. Carboprost Misoprostol ) Temperature Active Warming       . Group Specific. Platelets) Inotropic Support Uterine Massage / Compression Uterotonic Agents (Syntocinon .Massive Obstetric Haemorrhage Medical  Volume Replacement (Crystalloid.

Massive Obstetric Haemorrhage Surgical • • • • • • EUA Repair Uterine Tamponade (78%) B-Lynch Suture (81%) Arterial Ligation Radiological Arterial Embolisation Hysterectomy ( 12%) .

Failure of conservative approach .Treatment of PPH: Hysterectomy  A conservative option should be quickly efficacious  The addition of successive conservative approaches is hazardous .Placenta accreta  Placenta accreta is a frequent cause of failure of .Uterine rupture .Risk of delaying radical treatment Early Decision conservative Treatments  Hysterectomy may be a life-saving procedure in case of .

Selective Angiographic Embolization (SAE) Strategically difficult in many centers .

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Pulmonary Embolism .

accounts for the leading cause of maternal mortality in the United States (Koonin. et al. MMWR) .Pulmonary Embolism Pulmonary embolism. along with amniotic fluid embolism.

DVT: Key Facts • 40% of asymptomatic patients with DVT have radiographically documented pulmonary embolism • DVT of pelvic venous system is often an asymptomatic condition until clinical pulmonary embolism develops • Untreated pulmonary embolism mortality is up to 30%. Treated mortality is 3% .

0 .High  Score 2.PE likely.0 points alternative diagnosis is less likely than PE . .1.  Score 4 or less .5 points hemoptysis . Consider D-dimer to rule out PE.The Wells score        clinically suspected DVT .0 points malignancy (treatment for within 6 months.1. Consider diagnostic imaging.0 to 6.3.1.0 points Traditional interpretation  Score >6.5 points immobilization/surgery in previous four weeks .0 .1.5 points history of DVT or PE .PE unlikely.Moderate  Score <2.Low Alternate interpretation  Score > 4 .0 .3.1.0 points Tachycardia . palliative) .

Diagnosis of Pulmonary Embolism • D-dimer (0-300 ng/ml as normal) • Chest X-ray • ECG • Arterial blood gas • Ventilation-perfusion scintography • Angiography • Thoracic enhanced CT (64 slices MDCT) • Extremity Doppler .

Chest X-Ray Findings in PE: • Hampton’s Hump: pleural based density at CPJ • Westermark’s Sign: peripheral aligemia with proximal vessel dilatation • Most common finding is normal X-Ray (30%)! .

RBBB.ECG Changes in PE: • p-pulmonale. RAD • S1 Q3 T3 classic signs -large S wave in lead I -a large Q wave in lead III and -an inverted T wave in lead III • New Onset A-Fib • Most common finding is normal (or sinus tach) ECG .

Radiographic Diagnosis of Pulmonary Embolism During Pregnancy: • Ventilation/Perfusion (V/Q) Scanning • Pulmonary Angiography • Spiral/Helical CT .

Pulmonary Embolism in Pregnancy • Anticoagulation is mainstay of pharmacotherapy • Supportive care should not be forgotten during the rush to diagnose and treat .Treatment.

Exteriorization of Uterus .

High Uterine wound Air Embolism .Venous Air Embolism  During the repair of hysterotomy wound  Exteriorization of the uterus and traction on the wound edges increases the risk  Trendelenburg position to be avoided  Abdominal and Uterine incision always below heart  CVP.

Amniotic Fluid Embolism “Anaphylactoid syndrome of pregnancy" .

unpreventable and -an untreatable (for the most part) obstetric emergency .Amniotic Fluid Embolism AFE is an .unpredictable .

000 Pregnancies • Catastrophic Consequences • Multisystem Collapse • Mortality Quoted as High as 80% (Probably Lower Now) .1/20.000 .1/15.Amniotic Fluid Embolism • Frequency.

.First Victim of AFE 1817 an obstetrician named Sir Richard Croft  The patient was Princess Charlotte of Wales  She died. presumably from an undetected post-partum haemorrhage  Condemnation and grief Croft experienced led him to commit suicide  Charlotte's pregnancy is known in medical history as  “the triple obstetrical tragedy”.

Animal Data: • Amniotic fluid thought to be composed of some abnormal factor or mediator • Factor is heat stable • Factor is soluble? • Possible relationship with anaphylactoid phenomenon • Abnormal components such as meconium may play a role (Hankins. 1993. Hankins. 1995) . et al.Pathophysiology. 1995. Clark.

NOT RELATED • Drug Allergy and/or Atopy.AFE registry suggests that hyperstimulation is EFFECT rather than cause of AFE • Oxytocin use. with 41% of patients in AFE registry with allergies • Normal labor!!?? (Clark. 1997) Situations Related or NOT Related to AFE: .RELATED.• Uterine Hyperstimulation.

Amniotic Fluid Embolism Mechanis m .

Clinical presentation
The classic clinical presentation of the syndrome has been described by five signs that often occur in the following sequence: (1) Respiratory distress (2) Cyanosis (3) Cardiovascular collapse cardiogenic shock (4) Hemorrhage (5) Seizure & Coma.

Diagnosis

The presence of squamous cells in the pulmonary arterial blood obtained from a Swan-Ganz catheter once considered pathognomonic for AFE is neither sensitive nor specific The monoclonal antibody TKAH-2 may eventually prove more useful in the rapid diagnosis of AFE.

National registry’s criteria for diagnosis of amniotic fluid embolism

AFE.Differential Diagnosis • • • • • • Pulmonary Embolism Venous Air Embolism Myocardial Infarction Eclampsia Anaphylaxis Local Anesthetic Toxicity .

.Management of AFE RECOGNITION FIRST STEP  IMMEDIATE MEASURES : .Airway control endotracheal intubation maximal ventilation and oxygenation. . -O2 administration.Set up IV Infusion.

Other investigators have used vasopressor therapy such as ephedrine or levarterenol with success (reduced . increase the circulating volume and cardiac output with crystalloids. restrict fluid therapy to maintenance levels since ARDS follows in up to 40% to 70% of cases.Management of AFE      Treat hypotension. After correction of hypotension. Steroids may be indicated (recommended but no evidence as to their value) Dopamine infusion if patient remains hypotensive (myocardial support).

RESUSITATION OF CARDIAC ARREST .

you are wrong!  Being an Obstetrics provider is no excuse not to be CPR literate. etc. fetal evaluation. .  Non-Obstetrics providers may know more than you do about CPR.Cardiopulmonary Resuscitation in Pregnancy  If you think that this will never happen to you. but they may know little or nothing about pregnancy.

babies die or impaired • Mother brain damaged. babies intact • Family takes legal action against hospital. obstetrician .Possible Outcomes • Mother and babies die or brain-damaged • Mother and babies intact • Mother intact. anesthesiologist.

Cardiac Arrest in Pregnancy What happens next depends on:    Maternal diagnosis Fetal condition and maturity How rapidly and appropriately medical and nursing personnel respond Resources available in hospital  .

obesity     .Cardiac Arrest in Pregnancy: Complicated by Physiologic Changes  Rapid development of hypoxia. hypercapnia. acidosis Risk of pulmonary aspiration Difficult intubation AORTO-CAVAL COMPRESSION by pregnant uterus when mother supine Changes greater in multiple pregnancy.

Cardiac Arrest in Pregnancy: Special Problems • • Cardiac output during closed chest massage in CPR is only ~ 30% normal Cardiac output in the supine pregnant woman is decreased 30-50% due to aortocaval compression • Combined effect of above: There may be NO cardiac output! .

MRI Scan • NORMAL • Aortocaval Compressionoccurs during second 1/2 of pregnancy .

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Cardiff Resusitation Wedge .

AIRWAY .

AIRWAY CORRECTION .

may be better than intubation attempts Use of amiodarone 300 mg IV (in place of lidocaine*) Vasopressin 40 mg x 1 (alternative to repeated doses epinephrine 1 mg IV every 3-5 min*) Family presence during resuscitation American Heart Association.An international evidence and science-based consensus: What’s new or different?    Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiac Care Anticipatory treatment of cardiac arrest Emphasis on Automatic External Defibrillators (AEDs) Competent bag-mask ventilation . 2000    *Insufficient evidence to support efficacy .

Why is Urgent Delivery Indicated?      Maternal brain damage may start at ~ 4-6 min What is good for mother is usually good for baby Most intact newborns delivered within 5 min Closed chest massage is less effective with time CPR may be totally ineffective before delivery: Many reports of mother “coming back to life” after delivery .

Advantages of Early Delivery  Aortocaval compression relieved: Venous return . CO2 production  Improved maternal and newborn survival . Cardiac output  Ventilation improved: -Functional Residual Capacity  -Oxygenation improved    Oxygen consumption .

can it be improved? .Not an Easy One! • Has 3-4 min passed since cardiac arrest? • Has the mother responded to resuscitation? • Was resuscitation optimal .The Cesarean Delivery Decision .

deliver by 5 minutes (From the time of Arrest) Perform operation in patient’s room: Can move to OT after delivery Don’t worry about sterility Vertical abdominal incision quickest Prepare for uterine hypotonia and bleeding     .“Perimortem” Cesarean Section  Start by 4 minutes.

Optimal Outcome Immediate CPR  ACLS ⇒ Early intubation IS THIS REALISTIC   OUTSIDE THE OR? Left Uterine displacement Start Cesarean by 4 min Delivery by 5 min .

defibrillator Automatic Electric Defibrillator (AED)? Cesarean section instruments Difficult intubation equipment (including LMA. jet ventilator.Essential Equipment (Should be available in Labour ward)      Pulse oximeter Cardiac arrest cart. fiberoptic laryngoscope) Thoracotomy instruments Blood warmer and rapid fluid infuser Central venous and arterial line equipment    .

for airway. vascular..Common Problems in Obstetrics      Denial of problem  delay in response Communication errors Obstetric staff not prepared for catastrophes Inadequate response from transfusion or labs No specialty in-house surgeons (e. cardiac problems) No OB-ICU facilities  .g.

keep their family members well informed. .  Get informed consent at each stage.  Be cool and calm while communicating with the family members  Allow as much access to the loved ones as possible.Family Support  When the mother and infant are gravely ill.

WORK FORCE & PROTOCALS .

• In such emergency situation It appears important to: – Streamline the workflow – Co-ordinate the efforts of .

 revealed blood  –Maintenance of haemodynaemic status of patient loss – Fluid & blood product replacement • Assessment of blood loss • Estimation of blood loss – Estimation of blood loss is notoriously  –More experienced in blood loss estimation difficult & inaccurate • Anaesthesia • Control bleeding – Induction a & maintenance of anaesthesia –Manual pressure. BP. operative  • Drug administration procedures 5 Elements in management               ІІІOperating Theatre • Preparation for emergency operation • Assistance in operative procedures – Scrub nurse to conduct operation – Assist in administration of anaesthesia – Assist in fluid.                ІObstetrician                        ІІAnaesthetist • Assessment of patient condition • Resuscitation – General condition. oxytocic. blood product and drug administration                  ІV Radiologist • Control of haemorrhage – Cannulisation of pelvic vessels – Embolization of pelvic vessels to control bleeding                 VPaediatrican • Resuscitation of newborn – Stand by delivery – Immediate resuscitation of newborn – Escort newborn to NICU . pulse.

Multidisciplinary Team Approach .

Multidisciplinary Team Approach .

structure and the availability of Resource persons • Update and modify your Protocal periodically • Conduct periodic Emrgency drill .Hemorrhage protocol Logistics • Protocal should be specific for your hospital •Determine the hemorrhage response team •Determine team member responsibilities (Hospital specific) • Protocal depends upon your hospital infra.

Early Haemorrhage Early Recognition Hypotentio n Prevent shock Shock Resusitation CPR Cardiac Arrest Late intervention Early intervention Deliver the baby < 5mts .

Summary Successful treatment requires:  Communication  Preparedness  Multidisciplinary Team Approach  Hospital Hemorrhage Protocol .

A Good understanding between MULTIDISCIPLINARY TEAM IS A MUST FOR THE SUCCESS .

skilled supervision. prompt detection and can prevent disastrous consequences .Intelligent anticipation. effective institution of thera .

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