PART 4 (Slides 31–40) Diagnosis and Emergency Management of Postpartum Hemorrhage (PPH) in a Simulated Environment SLIDE 31 Cause-Specific Management: "Treat the 4 Ts" After Initial Resuscitation Simultaneously identify and treat the underlying cause. Cause Management Tone Uterine massage, uterotonics, balloon tamponade, surgery Trauma Repair tears, evacuate hematoma, laparotomy if required Tissue Remove retained placenta/products Thrombin Correct coagulation defects with blood products Key Principle Resuscitation and cause-specific treatment must proceed together. SLIDE 32 Management of Uterine Atony (Tone) Stepwise Approach Call for help. Perform uterine massage. Empty the urinary bladder (insert Foley catheter). Start oxytocin immediately. Add additional uterotonics if needed: Methylergometrine Carboprost Misoprostol Administer Tranexamic Acid. Continue fluid and blood replacement. If bleeding persists → Balloon tamponade or surgery. Clinical Pearl Atony is the commonest cause of PPH—treat aggressively and early. SLIDE 33 Bimanual Uterine Compression Indication Persistent bleeding due to uterine atony while definitive treatment is being arranged. Technique One hand inserted into the vagina to elevate the uterus. Other hand compresses the fundus externally. Compress the uterus between both hands. Advantages Immediate reduction in bleeding. Temporary life-saving maneuver. Buys time until uterotonics or surgery take effect. Suggested Diagram Illustration of bimanual uterine compression. SLIDE 34 Balloon Tamponade Purpose Controls bleeding by applying pressure inside the uterine cavity. Types Bakri balloon Condom catheter balloon (low-resource settings) Sengstaken-Blakemore tube (modified use) Indications Persistent uterine atony despite uterotonics. Before proceeding to surgery. Advantages Minimally invasive Preserves fertility High success rate (≈80–90%) Suggested Image Bakri balloon in situ. SLIDE 35 Management of Trauma Examine for: Cervical tears Vaginal tears Perineal tears Episiotomy extension Uterine rupture Hematoma Treatment Adequate lighting and anesthesia. Repair lacerations with absorbable sutures. Drain large hematomas. Laparotomy for uterine rupture. Replace uterine inversion immediately. Clinical Pearl Persistent bleeding with a firm uterus strongly suggests trauma. SLIDE 36 Management of Tissue Retained Placenta Management Controlled cord traction (if placenta not delivered). Manual removal under anesthesia if indicated. Ultrasound if diagnosis is uncertain and patient is stable. Retained Placental Fragments Uterine evacuation under aseptic precautions. Placenta Accreta Spectrum Avoid forceful placental removal. Prepare for massive hemorrhage. Hysterectomy may be required. Clinical Pearl Always inspect the placenta after delivery to ensure completeness. SLIDE 37 Management of Thrombin (Coagulopathy) Principles Treat the underlying cause. Replace deficient clotting factors. Blood Components Component Indication Packed RBC Blood loss/anemia Fresh Frozen Plasma Prolonged PT/aPTT Platelets Platelet count <50,000/µL with bleeding Cryoprecipitate Low fibrinogen (<2 g/L) Monitoring PT/INR aPTT Platelet count Fibrinogen Clinical bleeding SLIDE 38 Non-Pneumatic Anti-Shock Garment (NASG) What is NASG? A reusable neoprene garment that compresses the lower body to improve blood flow to vital organs. Indications Severe PPH with hypovolemic shock. During transport to a higher center. While preparing for surgery. Advantages Stabilizes circulation. Reduces mortality in low-resource settings. Easy to apply. Limitation Temporary stabilization only; definitive treatment is still required. Suggested Image Application of NASG. SLIDE 39 Stepwise Surgical Management If Conservative Measures Fail Conservative Surgical Options Examination under anesthesia (EUA) Compression sutures (B-Lynch, Hayman) Uterine artery ligation Utero-ovarian artery ligation Internal iliac artery ligation Definitive Surgery Subtotal hysterectomy Total hysterectomy Principle Early surgery saves lives when bleeding is uncontrolled. Do not delay in a deteriorating patient. SLIDE 40

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SLIDE 41 Uterine Compression Sutures Purpose Compression sutures mechanically compress the uterus to control bleeding while preserving fertility. Indications Persistent uterine atony despite uterotonics. Failure of balloon tamponade. Patient desires future fertility. Advantages Rapid and effective. Uterus is preserved. Avoids hysterectomy in many patients. Common Types B-Lynch suture (most commonly used) Hayman suture Cho square sutures Suggested Image: Diagram comparing B-Lynch, Hayman, and Cho sutures. SLIDE 42 B-Lynch Compression Suture Principle A continuous suture compresses the anterior and posterior uterine walls to stop bleeding. Indications Uterine atony during cesarean section. Failure of medical management. Advantages Controls hemorrhage rapidly. Preserves fertility. Simple to perform for trained surgeons. Possible Complications Infection Uterine ischemia (rare) Intrauterine adhesions (rare) Clinical Pearl B-Lynch is the first-choice compression suture in most centers. SLIDE 43 Uterine Artery Ligation Mechanism Reduces uterine blood flow by approximately 90%, allowing clot formation while maintaining collateral circulation. Indications Persistent bleeding despite uterotonics and compression sutures. Desire to preserve the uterus. Advantages Fertility-preserving. Less radical than hysterectomy. Possible Complications Injury to adjacent structures (rare). Failure requiring further surgery. SLIDE 44 Internal Iliac Artery Ligation & Uterine Artery Embolization Internal Iliac Artery Ligation Indications Severe uncontrolled pelvic hemorrhage. Experienced pelvic surgeon available. Benefits Reduces pelvic arterial pressure. Helps achieve hemostasis. Uterine Artery Embolization (UAE) Procedure Performed by an interventional radiologist. Catheter inserted through the femoral/radial artery. Embolic agents occlude uterine arteries. Advantages Minimally invasive. Preserves fertility. Avoids major surgery in selected stable patients. Limitation Requires specialized facilities. Not suitable for unstable patients needing immediate surgery. SLIDE 45 Obstetric Hysterectomy Definition Removal of the uterus to control life-threatening hemorrhage when all other measures fail. Indications Uncontrolled PPH Placenta accreta spectrum Uterine rupture Failure of conservative management Types Subtotal hysterectomy Total hysterectomy Principle Maternal life takes priority over fertility. Clinical Pearl Delayed hysterectomy increases maternal morbidity and mortality. SLIDE 46 Massive Obstetric Hemorrhage Protocol (MOHP) Definition A standardized multidisciplinary protocol for managing severe obstetric bleeding. Objectives Early recognition Rapid transfusion Correction of coagulopathy Definitive hemorrhage control Team Members Obstetrician Anesthetist Hematologist Blood bank Intensivist Nursing staff Benefits Reduces delays Improves maternal survival Enhances team communication SLIDE 47 Intensive Care Management Indications for ICU Admission Massive blood loss Persistent shock Need for ventilatory support Coagulopathy Multiorgan dysfunction Monitoring Continuous ECG SpO₂ Blood pressure Central venous pressure (if indicated) Urine output (>30 mL/hour) Serial hemoglobin and coagulation profile Goals Restore tissue perfusion Correct metabolic abnormalities Prevent organ failure SLIDE 48 Monitoring After Hemorrhage Control Clinical Monitoring Pulse Blood pressure Respiratory rate Temperature Oxygen saturation Mental status Fundal tone Vaginal bleeding Laboratory Monitoring Hemoglobin Platelet count PT/INR aPTT Fibrinogen Renal and liver function tests Urine Output Maintain ≥30 mL/hour as a marker of adequate renal perfusion. SLIDE 49 Complications of PPH Immediate Complications Hypovolemic shock Disseminated intravascular coagulation (DIC) Acute kidney injury Acute respiratory distress syndrome (ARDS) Cardiac arrest Death Late Complications Severe anemia Infection Sheehan syndrome Infertility (after hysterectomy) Psychological trauma Postpartum depression Clinical Pearl Early treatment prevents most complications. SLIDE 50 Maternal Outcome and Prognosis Good Prognosis When PPH recognized early. Prompt resuscitation initiated. Cause identified rapidly. Multidisciplinary management available. Poor Prognostic Factors Delay in diagnosis Delay in referral Inadequate blood transfusion Coagulopathy Massive blood loss Multiple organ dysfunction Key Message The "Golden Hour" is critical. Early recognition and aggressive management significantly improve maternal survival.

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SLIDE 51 Prevention of Postpartum Hemorrhage Prevention is Better Than Cure Antenatal Measures Identify high-risk pregnancies. Correct maternal anemia. Screen for placenta previa/accreta. Manage hypertensive disorders. Ensure institutional delivery for high-risk women. Intrapartum Measures Skilled birth attendance. Avoid prolonged or obstructed labour. Use oxytocin judiciously. Follow Active Management of Third Stage of Labour (AMTSL). Postpartum Measures Monitor uterine tone. Assess vaginal bleeding regularly. Monitor maternal vital signs. Key Message: Most cases of PPH can be prevented or managed effectively with timely interventions. SLIDE 52 Active Management of the Third Stage of Labour (AMTSL) Definition AMTSL is a package of interventions performed immediately after birth to reduce the risk of PPH. Components Administration of a uterotonic (Oxytocin). Delayed cord clamping (if appropriate). Controlled cord traction (when indicated and by trained personnel). Uterine massage after placental delivery (according to local protocol). Benefits Reduces incidence of PPH. Decreases blood loss. Lowers need for blood transfusion. Reduces maternal morbidity. Suggested Diagram: Flowchart of AMTSL steps. SLIDE 53 Uterotonics for Prevention of PPH First-Line Drug Oxytocin Dose: 10 IU IM or IV after delivery of the baby. Alternative Drugs (if Oxytocin is unavailable) Misoprostol Ergometrine (avoid in hypertension) Oxytocin + Ergometrine combination (where appropriate) WHO Recommendation Oxytocin is the preferred uterotonic for prevention of PPH whenever available and quality-assured. Clinical Pearl Administration of oxytocin within 1 minute after birth significantly reduces the risk of PPH. SLIDE 54 WHO Recommendations for PPH Management Key Recommendations Early recognition of excessive bleeding. Immediate administration of oxytocin. Early use of Tranexamic Acid (within 3 hours). Quantitative assessment of blood loss where feasible. Rapid fluid resuscitation. Timely blood transfusion. Escalation to surgical management when required. Team-based multidisciplinary approach. Goals Save maternal life. Prevent complications. Preserve fertility whenever possible. SLIDE 55 Simulation-Based Training Why Simulation? Simulation allows healthcare workers to practice emergency management without risk to patients. Learning Objectives Early recognition of PPH. Team communication. Clinical decision-making. Correct use of uterotonics. Effective resuscitation. Crisis resource management. Advantages Improves confidence. Improves teamwork. Reduces medical errors. Improves patient outcomes. Suggested Image: Obstetric simulation laboratory/mannequin. SLIDE 56 Equipment Required for PPH Simulation Airway Equipment Oxygen source Face masks Suction apparatus Laryngoscope Endotracheal tubes Circulation Equipment IV cannulas (14G/16G) IV fluids Infusion sets Blood collection tubes Obstetric Equipment Delivery tray Foley catheter Uterine balloon tamponade kit Suturing instruments Drugs Oxytocin Methylergometrine Carboprost Misoprostol Tranexamic Acid SLIDE 57 PPH Emergency Trolley Contents Drugs Oxytocin Tranexamic Acid Carboprost Methylergometrine Misoprostol Adrenaline (for emergencies) Equipment Syringes IV cannulas IV fluids Blood transfusion set Foley catheter Surgical gloves Suture material Balloon tamponade device Importance A well-stocked emergency trolley saves valuable time during obstetric emergencies. SLIDE 58 Team Communication During PPH Closed-Loop Communication Principles Give clear instructions. Repeat back instructions. Confirm completion of tasks. Document all interventions. Example Leader: "Administer Oxytocin 10 IU IV." Nurse: "Oxytocin 10 IU IV confirmed." Leader: "Thank you." Benefits Prevents errors. Improves coordination. Enhances patient safety. SLIDE 59 Simulation Scenario Clinical Case A 26-year-old G2P2 delivers vaginally. Ten minutes later she develops: Heavy vaginal bleeding. Pulse: 120/min BP: 80/50 mmHg Soft, boggy uterus. Questions What is your diagnosis? What is the most likely cause? What are your first five actions? Expected Answers Diagnosis: Primary PPH. Cause: Uterine atony (Tone). Actions: Call for help, ABCDE assessment, oxygen, two large-bore IV cannulas, uterine massage, oxytocin, send blood investigations, start fluids. SLIDE 60 Simulation Debriefing Discussion Points What Went Well? Early diagnosis. Team communication. Correct sequence of management. Timely uterotonics. What Could Be Improved? Faster activation of the PPH protocol. Earlier blood product request. Better documentation. More effective communication. Learning Outcome Simulation helps convert theoretical knowledge into practical skills, improving preparedness for real obstetric emergencies.