I want you to use the blow content to make a presentation. SLIDE 21 Emergency Response to PPH First 5 Minutes: "Golden Minutes" PPH is a medical emergency. Immediate action saves lives. Immediate Actions Recognize excessive bleeding. Activate the PPH emergency protocol. Call for senior obstetrician, anesthetist, pediatrician, blood bank, and nursing staff. Inform the operation theatre. Assign roles to team members. Record the time of diagnosis. Team Roles Team Member Responsibility Obstetrician Diagnose cause and control bleeding Anaesthetist Airway, circulation, resuscitation Nurses IV access, medications, monitoring Blood Bank Arrange blood and blood products Clinical Pearl: Never manage severe PPH alone. SLIDE 22 ABCDE Assessment A – Airway Ensure airway is patent. Position patient appropriately. Intubate if unconscious or airway is compromised. B – Breathing Administer 100% oxygen (10–15 L/min) via non-rebreather mask. Monitor SpO₂ continuously. C – Circulation Assess pulse and blood pressure. Insert two wide-bore (14G–16G) IV cannulas. Send blood for investigations. Start rapid fluid resuscitation. D – Disability Assess consciousness (AVPU/GCS). Check blood glucose if altered sensorium. E – Exposure Examine patient completely. Keep the patient warm to prevent hypothermia. SLIDE 23 Initial Resuscitation IV Access Two 14G–16G IV cannulas. Blood Samples CBC Blood grouping and cross-match PT/INR aPTT Fibrinogen Renal function tests Liver function tests ABG (if available) Monitoring Pulse Blood pressure Respiratory rate ECG SpO₂ Urine output Mental status Goal Restore circulating volume while controlling bleeding. SLIDE 24 Fluid Resuscitation Initial Fluids Warm isotonic crystalloids: Normal saline Ringer's lactate Recommendation Infuse 1–2 liters rapidly while arranging blood. Avoid Excessive crystalloids (>3 L) Delayed blood transfusion Monitoring Pulse Blood pressure Urine output Capillary refill Lactate (if available) Clinical Pearl Fluids temporarily restore circulation but do not replace blood loss. SLIDE 25 Blood and Blood Product Replacement Indications Continued bleeding Hemodynamic instability Hb <7 g/dL (or higher threshold if symptomatic) Blood Products Product Purpose Packed RBCs Restore oxygen-carrying capacity Fresh Frozen Plasma (FFP) Replace clotting factors Platelets Treat thrombocytopenia Cryoprecipitate Replace fibrinogen Massive Transfusion Protocol Approximate ratio: PRBC : FFP : Platelets = 1 : 1 : 1 Target Maintain: Hb >7–8 g/dL Platelets >50,000/µL Fibrinogen >2 g/L SLIDE 26 Uterine Massage Purpose Stimulates uterine contraction and reduces bleeding. Technique Place one hand over the uterine fundus. Massage using firm circular movements. Continue until the uterus becomes firm. Benefits Simple Immediate Effective in uterine atony Can be repeated Important Always perform uterine massage while preparing uterotonic drugs. Suggested Image: Technique of fundal massage. SLIDE 27 Uterotonic Drugs First-Line Medical Treatment Drug Dose Route Oxytocin 10 IU IM or slow IV Oxytocin infusion 20–40 IU in 1 L NS/RL IV infusion Methylergometrine 0.2 mg IM/slow IV Carboprost 250 µg IM (repeat every 15–90 min; max 8 doses) Misoprostol 800–1000 µg Rectal or sublingual Principle Use uterotonics early and do not delay escalation if bleeding continues. SLIDE 28 Oxytocin – Drug of Choice Mechanism Stimulates rhythmic uterine contractions. Compresses uterine blood vessels. Promotes hemostasis. Dose 10 IU IM after delivery OR 10 IU slow IV OR 20–40 IU in 1 L crystalloid as IV infusion. Advantages Rapid onset Highly effective Safe Few adverse effects Side Effects Hypotension (rapid IV bolus) Water intoxication (prolonged high-dose infusion) Clinical Pearl Oxytocin is the first-line uterotonic recommended by WHO. SLIDE 29 Other Uterotonics Methylergometrine Dose: 0.2 mg IM Contraindication: Hypertension Preeclampsia Heart disease Carboprost (15-methyl PGF₂α) Dose: 250 µg IM Repeat every 15–90 minutes Maximum: 8 doses Contraindication: Asthma Misoprostol Dose: 800–1000 µg Rectal or sublingual Advantages: Cheap Heat stable Useful in low-resource settings SLIDE 30 Tranexamic Acid (TXA) Mechanism Antifibrinolytic drug Prevents clot breakdown Stabilizes formed clots WHO Recommendation Administer within 3 hours of childbirth in women with PPH. Dose 1 g IV over 10 minutes Repeat 1 g if bleeding continues after 30 minutes or restarts within 24 hours. Benefits Reduces death due to bleeding Decreases need for surgery Effective for all causes of PPH when used early Contraindications Active thromboembolic disease (relative) Known hypersensitivity Key Message TXA should be given as early as possible along with standard PPH treatment—it is not a substitute for uterotonics or surgery.