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OBSTETRIC PPH DRILL

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OBSTETRIC DRILLS –PPH INDIA AUG 2016 6-11 TH HYDERABAD,CHENNAI,MUMBAI,KOLKATA,DELHI & LUCKNOW IAN DONALD SCHOOL OF ULTRASOUND & LUPIN 6 DAYS 6 CITIES HANDS ON TRAINING
Transcript
Page 1: OBSTETRIC PPH DRILL

OBSTETRIC DRILLS ndashPPHINDIA AUG 2016 6-11TH

HYDERABADCHENNAIMUMBAIKOLKATADELHI amp

LUCKNOW

IAN DONALD SCHOOL OF ULTRASOUNDamp

LUPIN6 DAYS 6 CITIES HANDS ON TRAINING

CONDUCTED BYbull ROBIN BURR(AUSTRALIA)bull SULLEN MILLER(USA)bull NARENDRA MALHOTRAbull SHEELA MANEbull JAIDEEP MALHOTRAbull ALKA KRIPLANIbull SADHNA GUPTAJAYAM KANANASHISH MUKERJEEVP PAILEYAPARNA SHARMASEEMA AMBUJA C

WELCOME

copy Suellen Miller 2016

OBSTETRIC DRILLSTHE PPH DRILL

PPH Drill

Jaideep MalhotraNarendra MalhotraNeharika MalhotraRAINBOW HOSPITALSwwwmalhotrahospitalscomwwwrainbowhospitalsorg

PPHDr Robin Burr

Worldwide issueOver 300000 women and 27 million newborn babies die each year in pregnancy and childbirth or soon afterwards the majority of them in Africa and South Asia

Every minute of every day somewhere in the world a woman dies from complications related to pregnancy or childbirth

99 of maternal deaths occur in the developing worldwwwwomenandchildrenfirstorguk

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 2: OBSTETRIC PPH DRILL

CONDUCTED BYbull ROBIN BURR(AUSTRALIA)bull SULLEN MILLER(USA)bull NARENDRA MALHOTRAbull SHEELA MANEbull JAIDEEP MALHOTRAbull ALKA KRIPLANIbull SADHNA GUPTAJAYAM KANANASHISH MUKERJEEVP PAILEYAPARNA SHARMASEEMA AMBUJA C

WELCOME

copy Suellen Miller 2016

OBSTETRIC DRILLSTHE PPH DRILL

PPH Drill

Jaideep MalhotraNarendra MalhotraNeharika MalhotraRAINBOW HOSPITALSwwwmalhotrahospitalscomwwwrainbowhospitalsorg

PPHDr Robin Burr

Worldwide issueOver 300000 women and 27 million newborn babies die each year in pregnancy and childbirth or soon afterwards the majority of them in Africa and South Asia

Every minute of every day somewhere in the world a woman dies from complications related to pregnancy or childbirth

99 of maternal deaths occur in the developing worldwwwwomenandchildrenfirstorguk

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 3: OBSTETRIC PPH DRILL

WELCOME

copy Suellen Miller 2016

OBSTETRIC DRILLSTHE PPH DRILL

PPH Drill

Jaideep MalhotraNarendra MalhotraNeharika MalhotraRAINBOW HOSPITALSwwwmalhotrahospitalscomwwwrainbowhospitalsorg

PPHDr Robin Burr

Worldwide issueOver 300000 women and 27 million newborn babies die each year in pregnancy and childbirth or soon afterwards the majority of them in Africa and South Asia

Every minute of every day somewhere in the world a woman dies from complications related to pregnancy or childbirth

99 of maternal deaths occur in the developing worldwwwwomenandchildrenfirstorguk

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 4: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

OBSTETRIC DRILLSTHE PPH DRILL

PPH Drill

Jaideep MalhotraNarendra MalhotraNeharika MalhotraRAINBOW HOSPITALSwwwmalhotrahospitalscomwwwrainbowhospitalsorg

PPHDr Robin Burr

Worldwide issueOver 300000 women and 27 million newborn babies die each year in pregnancy and childbirth or soon afterwards the majority of them in Africa and South Asia

Every minute of every day somewhere in the world a woman dies from complications related to pregnancy or childbirth

99 of maternal deaths occur in the developing worldwwwwomenandchildrenfirstorguk

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 5: OBSTETRIC PPH DRILL

PPH Drill

Jaideep MalhotraNarendra MalhotraNeharika MalhotraRAINBOW HOSPITALSwwwmalhotrahospitalscomwwwrainbowhospitalsorg

PPHDr Robin Burr

Worldwide issueOver 300000 women and 27 million newborn babies die each year in pregnancy and childbirth or soon afterwards the majority of them in Africa and South Asia

Every minute of every day somewhere in the world a woman dies from complications related to pregnancy or childbirth

99 of maternal deaths occur in the developing worldwwwwomenandchildrenfirstorguk

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 6: OBSTETRIC PPH DRILL

PPHDr Robin Burr

Worldwide issueOver 300000 women and 27 million newborn babies die each year in pregnancy and childbirth or soon afterwards the majority of them in Africa and South Asia

Every minute of every day somewhere in the world a woman dies from complications related to pregnancy or childbirth

99 of maternal deaths occur in the developing worldwwwwomenandchildrenfirstorguk

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 7: OBSTETRIC PPH DRILL

Worldwide issueOver 300000 women and 27 million newborn babies die each year in pregnancy and childbirth or soon afterwards the majority of them in Africa and South Asia

Every minute of every day somewhere in the world a woman dies from complications related to pregnancy or childbirth

99 of maternal deaths occur in the developing worldwwwwomenandchildrenfirstorguk

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 8: OBSTETRIC PPH DRILL

Postpartum haemorrhage 1500 ml or more - all women who give birth vaginally

httpswomenwchaasnau

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 9: OBSTETRIC PPH DRILL

MDG - GOAL 5 IMPROVE MATERNAL HEALTH

- Maternal mortality ratio (per 100000 live births)

InitialValue

LastValue

2015Target

Achievingtarget in

5600 1900 1400 2021

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 10: OBSTETRIC PPH DRILL

Achieving Millennium Development Goal 5 is India seriousDileep Mavalankar Kranti Vora M PrakasammaIndia - largest number of births per year (27 million) in the world Maternal mortality of about 300ndash500 per 100 000 births about 75 000 to 150 000 maternal deaths occur every year in Indiabull Absence of focus on emergency obstetric carebull Missing midwivesbull Lack of management capacity in the health systembull No political willbull Absence of comprehensive maternal care services

Bulletin of the World Health OrganizationgtPast issuesgtVolume 86 2008gtVolume 86 Number 4 April 2008 241-320

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 11: OBSTETRIC PPH DRILL

MMR India over time

Year MMR1990 5561995 4712000 3742005 2802010 2152015 174

Source WHO UNICEF UNFPA World Bank Group and UNPD (MMEIG) - November 2015

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 12: OBSTETRIC PPH DRILL

Maternal Mortality

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 13: OBSTETRIC PPH DRILL

DefinitionsPrimary PPH

gt 500 ml (spontaneous delivery)gt 1000 ml (caesarean section)

Severe haemorrhage blood loss gt 150 mlmin (within 20 min causing loss of more

than 50 of blood volume)sudden blood loss gt 1500-2000 ml (uterine atony loss of 25-

35 of blood volume)

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 14: OBSTETRIC PPH DRILL

Causes of PPH the 4 TrsquosTone uterine atony distended bladder

Trauma uterine cervical or vaginal injury

Tissue retained placenta or clots

Thrombin pre-existing or acquired coagulopathy

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 15: OBSTETRIC PPH DRILL

Antenatal risk factorsbull Polyhydramnios bull Multiple pregnancy bull Fibroids bull Past PPH bull Previous retained placenta bull Previous Caesarean Section uterine

surgery bull Placenta praeviapercreta increta bull APH

bull High parity bull Maternal Age bull Obesity bull Drugs eg NifedipineMgSO4

salbutamol bull Hypertensive disorders bull Pre-existing coagulation disorder

eg Von Willebrandrsquos bull Therapeutic anticoagulation bull Anaemia

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 16: OBSTETRIC PPH DRILL

Intrapartum risks

bull Fetal demise in utero bull Abruption bull Inductionaugmentation of

labour bull Prolonged labour bull Pyrexia bull Prolonged ruptured

membranes

bull Instrumental delivery bull Episiotomy bull Retained

placentamembranes bull Physiological third stage bull Drugs eg inhaled

anaesthetic agents bull Therapeutic anticoagulation

DIC

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 17: OBSTETRIC PPH DRILL

Third stage of Labour

PPH ACTIVE EXPECTANT

gt500 mls 5 13

gt1000 mls 1 3

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 18: OBSTETRIC PPH DRILL

Active vs Expectant Management

Outcome Control Rate Relative Risk 95 CI NNT dagger 95 CIPPH of 500 mL 14 038 032-046 12 10-14PPH of 1000 mL 26 033 021-051 55 42-91

Hemoglobin lt 9 gdL 61 04 029-055 27 20-40

Blood transfusion 23 044 022-053 67 48-111

Therapeutic uterotonics 17 02 017-025 7 6-8

CI Confidence intervaldagger NNT Number needed to treat

Prendiville WJ Elbourne D McDonald S Active versus expectant management in the third stage of labour Cochrane Database Syst Rev 2000 CD000007

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 19: OBSTETRIC PPH DRILL

AMTSL WH

1 2 3 4230

240

250

260

270

280

290

300

310

PPH Rate

1 2 3 400

20

40

60

80

100

120

Major PPH Rate

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 20: OBSTETRIC PPH DRILL

The GOLDEN HOURbull The first 60 minutes after the start of the PPHbull The greater the delay in starting resuscitation

the lower the percentage of survivors

bull However may not be true in trauma amp too late in PPH

bull FIRST 20 minutes

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 21: OBSTETRIC PPH DRILL

PPH ManagementASSESS

bull Observationsbull Cause of bleedingbull Investigations

ARRESTbull Fundal massagebull Drugs

REPLACEbull IV Fluids

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 22: OBSTETRIC PPH DRILL

Confidential enquiries (UK)TOO LITTLE

Uterotonics Fluid Blood Blood products

TOO LATE Recognition Reaction Intervention

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 23: OBSTETRIC PPH DRILL

Drugsbull Oxytocin - 10U IMIVbull Ergometrine - 500 mcg IVIMbull Prostaglandins

bull Carboprost ndash 250 mcg IM x8bull Misoprostol ndash 600 mg PO 800 mg PR

bull Carbetocin

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 24: OBSTETRIC PPH DRILL

Uterotonic Drugs

Drug Dosage Action Side Effects Caution

Oxytocin 10U IMIV Onset 2-3 minsLasts 10-15 mins Minimal None

Ergometrine 500mcg IVIM Onset 2-7 minsLasts 2-4 hours

Nausea vomiting headache

hypertensionHypertension

Carboprost 250mcg IM Onset 1-2 minsLasts 15-20 mins

Vomiting diarrhoea

bronchospasmBrittle asthma

Misoprostol800mcg SLPR

600mcg POOnset 3-5 mins

Peak 20-30 minsLasts lt75 mins

Shivering rise in temperature None

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 25: OBSTETRIC PPH DRILL

Misoprostol FIGO

bull A single dose of misoprostol 600μg orally for prevention

bull One dose of misoprostol 800 μg sublingually for treatment

bull Administered immediately after delivery of the newborn

bull Contraindications - History of allergy to misoprostol or other prostaglandin

bull FIGO 2012

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 26: OBSTETRIC PPH DRILL

Fluids

bull Colloids vs Crystalloidsbull Volumebull Warmbull Speedbull IV lines - Two large bore IV access

ndash GreyGreen (No 16 or 18)

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 27: OBSTETRIC PPH DRILL

IV AccessGauge Color Flow rate

16 Grey 180 mLmin18 Green 80 mLmin20 Pink 54 mLmin22 Blue 31 mLmin

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 28: OBSTETRIC PPH DRILL

Pressure Bag

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 29: OBSTETRIC PPH DRILL

Otherbull Airway breathing circulationbull Oxygen by face mask ndash 6 to 8L per

minutebull Fundal massagebull O negative bloodbull Cross matched bloodbull Massive Transfusion Protocol

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 30: OBSTETRIC PPH DRILL

Questions

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 31: OBSTETRIC PPH DRILL

Blood loss EstimationDr Robin Burr

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 32: OBSTETRIC PPH DRILL

The challengesbull Visual estimationbull Measuring aidsbull Clinical impactbull Shockbull MEOWS

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 33: OBSTETRIC PPH DRILL

Visual Estimation of Blood Lossbull Caregivers consistently underestimate

visible blood loss by as much as 50 Razvi K Chua S Arulkumaran S Ratnam SS A comparison between visual estimation and

laboratory determination of blood loss during the third stage of labor Aust N Z J Obstet Gynaecol 199636152ndash4

bull Can be improved with training using visual aidsBose P Regan F Paterson-Brown S Improving the accuracy of estimated blood loss at

obstetric haemorrhage using clinical reconstructions BJOG 2006 Aug113(8)919-24

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 34: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 35: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 1

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 36: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 37: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 2

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 38: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 39: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 3

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 40: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 41: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 4

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 42: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 43: OBSTETRIC PPH DRILL

Blood loss ndash quick quiz 5

bull 0 - 500 mlsbull 500 - 1000 mlsbull 1000 - 1500 mlsbull 1500 - 2000 mlsbull 2000 - 2500 mlsbull gt2500 mls

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 44: OBSTETRIC PPH DRILL

BRASSS-V Drapetrade

bull Placed under womanbull Two ties around waistbull Blood drains into

calibrated pouch

Kodkany BS Derman RJ Goudar SS et al Initiating a novel therapy in preventing postpartum hemorrhage in rural India a joint collaboration between the United States and India Int J Fertil Women Med 20044991ndash6

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 45: OBSTETRIC PPH DRILL

Kellyrsquos Pad

bull The patient sits on this device

bull The pad funnels the blood into a collection container which has a marked line at 500 mL

bull This device is washable and can be sterilized

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 46: OBSTETRIC PPH DRILL

Blood Mat

bull 20rdquo x 20rdquobull = 500mls

photo Pathfinder staffBangladesh

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 47: OBSTETRIC PPH DRILL

Local materials

Weighed gauze swabs pads

Kanga (100x155 cm) x2 = 500mls

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 48: OBSTETRIC PPH DRILL

PPH and shock

Blood Volume Loss Blood Pressure (systolic) Symptoms and Signs Degree of Shock

500-1000 mL (10-15) Normal Palpitations tachycardia dizziness Compensated

1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness tachycardia sweating Mild

1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness pallor oliguria Moderate

2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse air hunger anuria Severe

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 49: OBSTETRIC PPH DRILL

Monitoring MEWSbull Observation of vital signs are an integral part of carebull There is a potential for any woman to be at risk of

physiological deterioration and this cannot always be predicted

bull There is poor recognition of deterioration in conditionbull Regular recording and documentation of vital signs

will aid recognition of any change in a womanrsquos condition

bull The use of EWS chart prompts early referral to an appropriate practitioner who can undertake a full review order appropriate investigations resuscitate and treat as required

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 50: OBSTETRIC PPH DRILL

MonitorIdentify Trigger

AlertEvaluate

Diagnose

Respond

MATERNAL EARLYWARNING SYSTEM

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 51: OBSTETRIC PPH DRILL

MEOWS Chartbull All women whose clinical condition requires close

observation admitted early pregnancy antenatal or postnatal

bull All post operative cases ndash in recovery and following transfer from theatre

bull Any woman giving cause for concern (medical or obstetric causes)

bull DuringFollowing APHPPHEclampsia bull Suspected infection eg Prolonged SROMbull High-risk women in delivery suite (not in labour)

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 52: OBSTETRIC PPH DRILL

The Value of MEWS chartsbull 676 consecutive obstetric admissionsbull 200 patient (30) triggered and 86 patients (13) had

morbiditybull haemorrhage (43)bull hypertensive disease of pregnancy (31)bull suspected infection (20)

bull 89 sensitive (95 CI 81ndash95)bull 79 specific (95 CI 76ndash82)bull positive predictive value 39 (95 CI 32ndash46)bull negative predictive value of 98 (95 CI 96ndash99)

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 53: OBSTETRIC PPH DRILL

Questions

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 54: OBSTETRIC PPH DRILL

Obstetric HDUICUDr Robin Burr

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 55: OBSTETRIC PPH DRILL

Rationale for an Obstetric HDUbull Modified early warning scoring systems

improve the detection of life threatening illness

bull It is the subsequent management that will alter the outcome

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 56: OBSTETRIC PPH DRILL

Other drivers for changeCEMACH 1988 - 90 ldquoproperly equipped staffed and supervised high dependency area in every consultant obstetric unitrdquo

SAFER CHILDBIRTH - 2007 ldquoall obstetric units should be able to provide some high dependency carerdquo 1 in 100 deliveries

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 57: OBSTETRIC PPH DRILL

Advantages of an Obstetric HDUbull Concurrent availability of obstetric and critical care

management bull Awareness of physiology and pathology of the

maternity patientbull Fetal monitoring in antenatal patients bull Avoiding hazards of transfer bull Keeping mum and baby together bull Improved continuity of antenatal and postnatal care

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 58: OBSTETRIC PPH DRILL

Disadvantages of an Obstetric HDUbull Skill levels of MidwivesObstetric Nurses

bull Skill levels of Junior doctorsbull Anaesthetic supportbull Locationbull Equipmentbull ICU outreach

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 59: OBSTETRIC PPH DRILL

Levels of Carebull Level 0 - normal ward carebull Level 1 - needing more observation

Critical Carebull Level 2 - support of one organ

bull Basic respiratory ampor cardiovascular support bull Level 3 - advanced support

bull Advanced respiratory support alone bull Support of 2 or more organs

Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman | July 2011

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 60: OBSTETRIC PPH DRILL

Graduated response to deteriorationLow-score group (EWS =3)o Increased frequency of observations and the midwife in charge alerted

Medium-score group (EWS =4 5)o Urgent call to team with primary medical responsibility for the patiento Simultaneous call to personnel with core competences for acute illness

High-score group (EWS ge 6)o Emergency call to team with critical care competences and maternity team o There should be an immediate response

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 61: OBSTETRIC PPH DRILL

Admissions to HDUbull Obstetric Indications

ndash Eclampsiandash Sepsisndash Severe pre-eclampsiandash Severe asthmandash Major haemorrhagendash Diabetic ketoacidosisndash Thromboembolismndash HELLP syndromendash Puerperal sepsis

bull Non-obstetric indicationsndash Transfer from ICUndash Other surgical procedures or complicationsndash related to surgical conditionndash Pneumonia respiratory embarrassmentndash Hypertensionndash Renal impairmentndash Thyrotoxicosisndash Cardiac or neurological co-morbidityndash Morbid obesity (BMI gt40kgm2) with

comorbidities

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 62: OBSTETRIC PPH DRILL

Minimum equipment requirementso Piped oxygeno Suction equipmento Resuscitation equipment including ready access to defibrillatoro Pulse oximetero Non-invasive blood pressure monitoro ECG waveform monitoro Calf compression deviceo Invasive haemodynamic monitoringo Level 1 fluid infuser

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 63: OBSTETRIC PPH DRILL

Transfers out of HDUbull Failure of more than one organ systembull Disease requiring the expertise of specialist medical teams eg

bull Renal failure other than the impairment associated with preeclampsiabull Hepatic failurebull Respiratory disease especially that requiring ventilatory supportbull Cardiac disease pre-existing or of recent onsetbull Neurological conditionsbull Endocrine disease including diabetes mellitusbull Non-obstetric surgical problems

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 64: OBSTETRIC PPH DRILL

Transfer of carebull Guidelinesbull Clear planbull Timing of transferbull Continuity of carebull Structured formal handovers

bull summary of critical care staybull a monitoring plan detailing the frequency of observations bull An plan for ongoing treatmentbull physical and rehabilitation needs bull psychological and emotional needs bull specific communication or language needs

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 65: OBSTETRIC PPH DRILL

Discharges to wardbull Patient haemodynamically stable no further

continuous intravenous medication or frequent blood tests required

bull No invasive monitoring requiredbull No active bleedingbull No supplementary oxygen requiredbull Patient mobilized

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 66: OBSTETRIC PPH DRILL

ISBAR toolIdentification identify yourself and your role to the person you are communicating with in the communicationSituation describe the specific situation about a particular patient including name consultant patient location vital signs resuscitation status and any specific concernsBackground communicate the patientrsquos background including date of admission diagnosis current medications allergies laboratory results progress during the admission and other relevant informationAssessment this involves critical assessment of the situation clinical impression and detailed expression of concernsRecommendation this includes the management plan suggestions for care detail of investigation requests and expected time frame

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 67: OBSTETRIC PPH DRILL

UK Obstetric HDUbull Admissions rose from 267 to 501 bull Massive obstetric haemorrhage is now the most

common reason for admission bull Invasive monitoring in 30 bull Two-thirds of neonates (663) stayed with their

critically ill mothers in the high dependency unit bull Transfer to the intensive care unit was needed in 14

per 1000 deliveries conducted

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 68: OBSTETRIC PPH DRILL

Indian Obstetric HDUbull Admission rate - 94bull Severe PIH with complications - 26 bull Placenta praevia APH - 314 bull Abruptio placenta - 57 bull PPH - 14bull PROM with sepsis - 8 bull Medical complications in pregnancy - 242

bull HDU mortality rate was 37 (692 were preventable deaths)

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 69: OBSTETRIC PPH DRILL

Questions

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 70: OBSTETRIC PPH DRILL

Transfer of Patientwith PPH

PPH Module 2014

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 71: OBSTETRIC PPH DRILL

When to transfer the patient with PPHFrom PHC to First Referral unit Clinical assessment Class I Retained placenta Traumatic PPHFrom Nursing home with OT to Hospital with HDU amp ICU Uncontrolled Class IIFrom Labor room to OT Class II Retained placenta Traumatic PPH

(Do not wait till Class III amp IV)

PPH Module 2014

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 72: OBSTETRIC PPH DRILL

Prerequisites for TransferInformed consentAnti shock Garment (NASG)Check availability of bed in the referral hospitalReferral documentsIndwelling catheter with UrosacVaginal pack in traumatic PPHTamponade in atonic PPHRecord presence of PackTamponade ndash Do not remove until destination

PPH Module 2014

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 73: OBSTETRIC PPH DRILL

Referral DocumentsAntenatal Record with risk factorsIntranatal events Delivery notes VaginalInstrumentalC section Time of delivery of BabyPlacenta EpisiotomyVaginal lacerationCervical tearInvestigation results Sequence of events Medication administered with time amp dose Fluids administered Condition on Transfer

PPH Module 2014

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 74: OBSTETRIC PPH DRILL

On transferNasal Oxygen on flowTwo IV lines (1618) with fluid on flowNurse or Doctor amp Patientrsquos able attendant to accompany

PPH Module 2014

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 75: OBSTETRIC PPH DRILL

NASG Updates on Clinical Trial Results Implementation Trials Cost Effectiveness and

Global Guidelines

Professor Suellen MillerUniversity of California San FranciscoDept ObsGyn amp Reproductive SciencesDirector Safe Motherhood Program

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 76: OBSTETRIC PPH DRILL

What is the NASG

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 77: OBSTETRIC PPH DRILL

Used in Over 33 Countries Globally

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 78: OBSTETRIC PPH DRILL

Where in India

Pathfinder Raksha Project 2007-2012

Tamil Nadu Rajasthan Bijar Orrissa Maharashtra Assam Agra

Pathfinder and World Health Partners in UPDr Narendar Malhotra Rainbow HospitalsDr Sheela Mane throughout India

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 79: OBSTETRIC PPH DRILL

Clinical Trials Tertiary Level5 peer-reviewed studies 4 pre-post design 1 (India) contemporaneous use3651 women Severe OH (gt1000 mL) with clinical sxs of shock

1614 (453) standard care 1947 547 standard care + NASGSub-analysis of Severe Shock (1227 MAP lt 60 mm HG 594 std care 633 516 std care + NASG)

Meta-analytic Techniques to pool all data

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 80: OBSTETRIC PPH DRILL

Outcomes NASG Tertiary Level

bullLifeWrap significantly reduced mortality 48 RR 052 (95 CI 036-077)

Pileggi-Castro C Nogueira-Pileggi V Tuncalp O Oladapo OT Vogel JP Souza JP Non-pneumatic anti-shock garment for improving maternal survival following severe postpartum haemorrhage a systematic review (2015) Reproductive Health 1228

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 81: OBSTETRIC PPH DRILL

Clinical Trials Primary Level

Zambia and Zimbabwe 2007-2012880 women transported from PHCs midwifery directed no bloodsurgeryClinics randomized to standard care vs standard care plus NASG before transport for hypovolemic shock38 clinics 5 tertiary facilitiesOUTCOMES Mortality and Time to Recovery of Shock

Similar in magnitude of effect and trend of the Tertiary FacilitiesNon-pneumatic Anti-Shock Garment (NASG) a First-Aid Device to Decrease Maternal Mortality from Obstetric Hemorrhage A Cluster Randomized Trial Miller S Bergel EF El Ayadi A Gibbons L Butrick E Magwali T Mkumba G Kaseba C My Huong NT Geissler JD Merialdi M(2013) PLOS ONE 8(10) e76477

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 82: OBSTETRIC PPH DRILL

Pragmatic TrialImplementation Science 334 PHCs Rural Tanzania

Baseline all hemorrhage gt500 mLEndline Severe hemorrhage only gt1000 mL or signs of hypovolemia P lt 001

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 83: OBSTETRIC PPH DRILL

Cost-Effective Analyses

bull Comparison of CEA at Tertiary Level 1442 womenbull Egypt Cost BENEFICIAL save health system $100001000 women

with shockbull Nigeria Zambia Zimbabwe Extremely COST EFFECTIVE

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG) evidence from a cluster randomized controlled trial in Zambia and Zimbabwe Downing J El Ayadi A Miller S Butrick E Mkumba G Magwali T Kaseba-Sata C Kahn JG (2015) BMC 1537Use of the Non-pneumatic Anti-Shock Garment (NASG) for Life-Threatening Obstetric Hemorrhage A Cost-Effectiveness Analysis in Egypt and Nigeria Sutherland T Downing J Miller S Bishai DM Butrick E Fathalla MF Mourad-Youssif M Ojengbede O Nsima D Kahn JG (2013) PLOS ONE 8(4)e62282

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 84: OBSTETRIC PPH DRILL

Non-Pneumatic Anti Shock Garment(NASG)

PPH Module 2014

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 85: OBSTETRIC PPH DRILL

NASG (Life Wrap)

It applies pressure on the legs amp abdomenBlood returns to vital organs curbing internal bleedStabilizes BP until patient reaches appropriate hospitalEasy to applyApplication time takes lt 60 seconds in trained hands

PPH Module 2014

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 86: OBSTETRIC PPH DRILL

How does NASG work

It is a First AidControls bleeding through direct pressureAuto transfusion of blood in upward directionBall in abdominal segment applies focused pressure to uterusCircumferential pressure on lower half of the body reduces the total vascular spaceVital organs get increased blood supply amp oxygenationStabilization of patient during transport

PPH Module 2014

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 87: OBSTETRIC PPH DRILL

How does NASG work

In shock the brain heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs in addition to blood loss from the vagina during obstetric hemorrhage

The NASG applies circumferential counter pressure which reverses shock bull By returning blood to the vital organs bull Decreasing blood flow in the compressed areasbull Decreasing blood loss

PPH Module 2014

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 88: OBSTETRIC PPH DRILL

NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic ShockUsed with hemorrhage therapies uterotonics massage vaginal procedures even surgeriesDoes not compete with other approaches Not an either or situation first-aid device that buys timeA technology that can be used when patient with uterine atony does not respond to uterotonicsANDEffective for ALL obstetric hemorrhage rupture lacerations ectopicOnly technology that reverses shock until blood transfusions

Can be used with balloon tamponade to reverse shock

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 89: OBSTETRIC PPH DRILL

About NASG

NASG is light weight (1500 G)Compression suit made of NeopreneFive segments enclosing ankle thigh calves pelvis amp abdomenVelcro fastenings to keep garment tightA small foam ball in the abdominal segment applies pressure on the uterusMarkings on the sections show how to apply

PPH Module 2014

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 90: OBSTETRIC PPH DRILL

About NASG

Correct tight application supplies 20 to 40 mm Hg of circumferential pressure to lower body effectively reversing hypovolemic shockCan be easily packed back into carry bag

PPH Module 2014

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 91: OBSTETRIC PPH DRILL

NASG (Life wrap)

PPH Module 2014

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 92: OBSTETRIC PPH DRILL

Applying NASG

Step 1 Place NASG under the woman with the top at the level of lowest ribClose segment 1 tightly around ankle on both sidesSnap it until you hear a sharp sound

Step 2Close segment 2 around calf muscleLeave the knee joint free

PPH Module 2014

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 93: OBSTETRIC PPH DRILL

Applying NASGStep 3Apply segment 3 around the thighs

Step 4Apply segment 4 all around the woman with the lower edge at the level of pubic bone

PPH Module 2014

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 94: OBSTETRIC PPH DRILL

Applying NASG

Step 5Place segment 5 with pressure ball directly over umbilicusClose the NSAG using segment 6

Only one person should close segment 4 amp 5Should not be too tight to restrict breathing

PPH Module 2014

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 95: OBSTETRIC PPH DRILL

Applying NASG

Step 6Ensure patient is breathing normally after the applicationIn case of uterine atony administer uterotonics amp massage the uterus without removing the NASGNASG is flexible enough to allow the massaging

PPH Module 2014

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 96: OBSTETRIC PPH DRILL

Vaginal Procedures with NASG in situ

Pelvic examinationLithotomy positionRepair of episiotomy Perineal tear Vaginal laceration Cervical tearMRPBimanual compressionDampC DampE MVA

PPH Module 2014

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 97: OBSTETRIC PPH DRILL

Surgery with NASG in situLaparotomy (Keep segments 12amp3 in situ and open pelvic amp abdominal segments 45amp6 just prior to incision)Steep Trendelenberg positionOperate quicklyReplace segment 4 5 amp 6 after procedure

PPH Module 2014

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 98: OBSTETRIC PPH DRILL

Special situations

Obese women

Short stature

Need for defecation

Replacing soiled NASG

PPH Module 2014

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 99: OBSTETRIC PPH DRILL

When to remove NASGPatient must be stable for 2 hoursBleeding lt50 mlhr Pulse lt100 BPMSystolic BP 90-100 mm Hg Hb gt7G Patient conscious amp aware

PPH Module 2014

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 100: OBSTETRIC PPH DRILL

How to remove NASGRemove segment 1 amp wait for 15 mtsCheck pulse amp BPIf pulse rate increases gt20 BPM or BP falls by 20 mm Hg Reapply segment 1If vitals stable remove segment 2Follow same principles till removal of segment 6

PPH Module 2014

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 101: OBSTETRIC PPH DRILL

Do not remove NASG before all vital signs are restored

Early removal of NASG can be dangerous or even fatal

PPH Module 2014

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 102: OBSTETRIC PPH DRILL

CautionIf BP falls by 20 mm Hg or Pulse increases by 20 BPM after removal of any segment rapidly replace all segments

Consider need for crystalloids Blood

If recurrent bleeding determine source amp arrest

PPH Module 2014

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 103: OBSTETRIC PPH DRILL

Storing NASG

Clean NASG with running water amp disinfectant and dryKeep folded NASG in a clear plastic bagStore NASG in a place where it is visible amp accessibleAlways store at the same placeEnsure every one knows place of storageStorage place should be displayed prominentlyThe referral center must send a replacement NASG after receiving the patient

PPH Module 2014

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 104: OBSTETRIC PPH DRILL

Relative contraindications

Cardiac failurePre existing Mitral stenosis Pulmonary edema Advanced pregnancy with live fetus (APH)Abdominal eviscerationOpen pelvic fracture

PPH Module 2014

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 105: OBSTETRIC PPH DRILL

Principles to be observedOne person alone can apply NASGTwo persons needed when patient is unconsciousUrine output should be measuredEnsure airway protection amp Prevent aspirationEnsure one on one nursing care

PPH Module 2014

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 106: OBSTETRIC PPH DRILL

Advantages of NASG50-78 Reduction in blood loss

50-55 Reduction in Maternal Mortality amp related Morbidity

WHO includes NASG in recommendations

Cost effective

Reusable

PPH Module 2014

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 107: OBSTETRIC PPH DRILL

World Scenario 2013Used in 16 Countries

UK amp USARemote Rural areas

Jehovarsquos witness

Zambia ampZimbabwePeri urban

centers

Tamil NaduAll levels

Ambulance108

PPH Module 2014

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 108: OBSTETRIC PPH DRILL

Added toWHOGuidelinesfor PPH in2012

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 109: OBSTETRIC PPH DRILL

FIGO Guidelines

1 Non-pneumatic anti-shock garment to stabilize women with hypovolemic shock secondary to obstetric hemorrhage FIGO Safe Motherhood and Newborn Health Committee (2014) httpdxdoiorg101016jijgo201410014

2 FIGO GUIDELINES Prevention and treatment of postpartum hemorrhage in low-resource settings FIGO Safe Motherhood and Newborn Health (SMNH) Committee International Journal of Gynecology and Obstetrics 117 (2012) 108ndash118 doi101016jijgo201203001

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 110: OBSTETRIC PPH DRILL

Partnership for Distribution in LMICEMECUN

bull United Nations Commission on Life Saving Commodities for Women and Childrenrsquos Healthbull CHAIbull UCSFSafe Motherhood Programbull BlueFuzion UNGM (United Nations Global Marketplace)bull Higher Quality Lower Price Increased Reusability

bull $030 usebull $4200garment and WashReuse Cycles ~ 140 times

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 111: OBSTETRIC PPH DRILL

Hemorrhage Etiologies UCSF

29

11

16

12

4

7

2

19Atony

Lacerations

Retained

Placenta

Ruptured Ut

Ectopic

Other

Abortion

N = 4191

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 112: OBSTETRIC PPH DRILL

Safety

gt 10000 documented casesNO REPORTS of any safety issuesNO INCREASE of side effects minor or major due to use of NASG

Used now routinely in AfricaAsiaSouth AmericaLarge-Scale Pragmatic ldquooperations researchrdquo in Tanzania East Timor and others

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 113: OBSTETRIC PPH DRILL

Conclusions

bullStatistically significant decreases in time to return to normal Shock Index in quasi-experimental and RCTs bullAt the TERTIARY LEVEL~ 58 significant reduction in MORTALITY across several quasi-experimental studiesbullRandomized Trial at PHCEarlier Application 64 reduction in mortality ns bullCost Effective or Cost-BeneficialbullOn WHO and FIGO GUIDELINES UN Marketplace VendorNASG AICOG bullIn 10000 cases carefully documented there were no adverse events related to NASG use SAFEbullNow in use in over 33 countries globally

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 114: OBSTETRIC PPH DRILL

QUESTIONS

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 115: OBSTETRIC PPH DRILL

PPH Module 2014

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 116: OBSTETRIC PPH DRILL

Thank You

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 117: OBSTETRIC PPH DRILL

Innovations in Triage and Treatment of Obstetric Hemorrhage

PRESENTED BYPROF NARENDRA MALHOTRAMDFICOGFICMCHFICSFRCOG

copy Suellen Miller 2016

Professor Suellen MillerUniversity of California San Francisco

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 118: OBSTETRIC PPH DRILL

the most common and severe type of obstetric haemmorrhage is still an enigma to the present day obstetrician as it is sudden often unpredicted assessed subjectively and can be catastrophic The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period

POST PARTUM HAEMORRHAGE

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 119: OBSTETRIC PPH DRILL

Identify PPH Risk Factors

bull Pre-eclampsiabull Nulliparitybull Multiple gestationbull Previous post-partum haemorrhagebull Previous caesarean sectionbull 60 have no risk factors

bull Prolonged 1st amp 2nd stagebull Prolonged active third stage (gt30 min)bull Arrest of descentbull Episiotomybull Lacerations cervical vaginal perinealbull Assisted birthbull Use of oxytocics

Ante-natal

Intra-partum

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 120: OBSTETRIC PPH DRILL

Be Ready for it all the time l

Drill is a practice and anticipation amp task allotment to tackle emergencies Fire drillearth quake drill etc etcPPH drill should be taught practised and rehearsed in obstetric set up so that every one is prepared for the emergency and know what to do

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 121: OBSTETRIC PPH DRILL

136

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 122: OBSTETRIC PPH DRILL

Emergency Trolley

Endotracheal tube Laryngoscope

Essential drugs

Crystalloids giving sets haemacel

Emergency protocols

GENERAL MANAGEMENT

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 123: OBSTETRIC PPH DRILL

Large bore IV cannulas (gauge 14 x 2)Crystalloids

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 124: OBSTETRIC PPH DRILL

Teamwork

Key learning points

To understand the importance of good team workingTo understand that effective communication is vital in emergency situationsTo appreciate the different roles and responsibilities of members of a multiprofessional teamTo understand the importance of shared decision making within the teamTo recognise the value of being able to lsquostand back and take a broader viewrsquo in an emergency situation

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 125: OBSTETRIC PPH DRILL

TRIAGE Early Identification of Hemorrhage

First Delay

Recognizing Complications

Second Delay

Deciding to Seek Care

Third DelayAccessing Transport

Fourth Delay

Receiving Care at Facility

TRIAGE Early Identification of HemorrhageTREATMENTS Stop Bleeding Stabilize for Transport

copy Suellen Miller 2016

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 126: OBSTETRIC PPH DRILL

Low Tech Blood Loss Assessment

350 mL

500 mLcopy Suellen Miller 2016

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 127: OBSTETRIC PPH DRILL

GOES UNDER THE BUTTOCK OF MOTHER

RINGS-A string from each go around the buttockto be tied together suprapubically for double fixing

REUSABLE TYPE BLOOD COLLECTOR PAN

(DEBDAS)

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 128: OBSTETRIC PPH DRILL

Vital Signs as PredictorsBlood loss estimate not a reliable predictor of outcomePulse and Blood Pressure measurements are often difficult to obtain accuratelyPP Circulatory changes VS changes may be detected too lateMore sensitive predictor of adverse outcomes and management tool neededShock Index PulseSystolic BP

copy Suellen Miller 2016

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 129: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

Developed by Kingrsquos College LondonProf Andrew Sheenan Hannah NathanNatasha Helzegrave

CRADLEMicrolifeTraffic Light Vital Sign Alert (VSA)

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 130: OBSTETRIC PPH DRILL

Suitable for Use in Low Resource Setting

Parati et al 2005

bull Accuratebull Affordable - $19 per unitbull Easy to use bull Robustbull Low power requirementsbull A lifetime use of gt20000 extreme inflationsbull Can be used with a stethoscope as an alternative to a mercury columnbull Hypertensive Disorders amp HypertensionShock

copy Suellen Miller 2016

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 131: OBSTETRIC PPH DRILL

Shock Index ThresholdsHRSBP

SI ge 17

SI 09 ndash 169

SI lt09

Nathan HL El Ayadi AM Hezelgrave NL Seed P Butrick E Miller S et al (2015) Shock index an effective predictor of outcome in postpartum haemorrhage BJOG 122(2)268-75

copy Suellen Miller 2016

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 132: OBSTETRIC PPH DRILL

KCL CRADLE Researchbull Prospective clinical evaluation of device and traffic light system ongoing in South Africabull Larger Prospective Stepped Wedge Randomised Trial

Collaborating with KLE University IndiaEvaluating impact of CRADLE VSA on maternal deaths SMOs in 10 low-

income country sites

copy Suellen Miller 2016

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 133: OBSTETRIC PPH DRILL

Phone Pulse Oximeter

Pulse Oximeter noninvasive measures oxygen saturation by shining infrared light through the finger (measures redness of blood) low oxygen saturation in hypovolemic shockThe Phone Oximeter is a smartphone application which receives data in real time from a connected pulse oximeterMinimal Training lt$5000unitDeveloped at University of British Columbia part of Global PRE-EMPT

copy Suellen Miller 2016

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 134: OBSTETRIC PPH DRILL

Triage TRIGGER ACTION

Recognition of HemorrhageShockINITIATE ACTION Stop Bleeding

Medical Treatment bull UterotonicsCarboprost (025 mg IM)bull TXA IV administrationbull Pressure Massage Bimanual Compression Aortic Compression

Treat ShockIV fluidsWarmth Trendelenberg

ReferraltransportDefinitive Therapies

bull Bloodbull Surgery copy Suellen Miller 2016

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 135: OBSTETRIC PPH DRILL

LifeWrapNASGUnique first aid device reverses shock and decreases blood loss mitigates delays in transport and at facilitiesTested on 10000 women 5 studies Systematic Review published in BMC RH showed ss 48 decrease in mortality ss 69 reduction in SMOWHO FIGO AICOG PPH GuidelinesUnited Nations Commission on Life Saving Commodities for Women and Childrenrsquos Health CHAIUCSFSafe Motherhood Program and Blue Fuzion$030 use--$4200 and Wash Cycles gt 100

copy Suellen Miller 2016

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 136: OBSTETRIC PPH DRILL

Laerdal Compression Belt

St Georgersquos Hospital and University of LondonCurrently being tested in Sri LankaUterinepelvic vessel compression with an inflatable cuff on the uterus and an inflatable cuff on a suprapublic wedge

VS Talaulikar et al IJGO 2015 A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women copy Suellen Miller 2016

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 137: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

University of Liverpool The ButterflyProf Andrew Weeks

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 138: OBSTETRIC PPH DRILL

Improving on Current Treatments

copy Suellen Miller 2016

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 139: OBSTETRIC PPH DRILL

Innovative ultra low cost (less than USD $3 per UBT device) package

DeviceTargeted trainingChecklists

ESM-UBTTM

bull 235 women severe hemorrhage arrested in 233 of 235bull 98 of women with severe uncontrolled hemorrhage

survived bull Survival fell to 83 if an improvised UBT device was used

instead of one that was prepackaged and readily availableMass General Global Health Thomas Burke

Burke TF et al A postpartum hemorrhage package with condom UBT A prospective multi-center case series in Kenya Sierra Leone Senegal and Nepal BJOG July 21 2015copy Suellen Miller 2016

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 140: OBSTETRIC PPH DRILL

The UBT device arrests hemorrhage directly at the site of disrupted vessels

copy Suellen Miller 2016

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 141: OBSTETRIC PPH DRILL

PATHSINAPI UBT KIT

PATH is working closely with SINAPI biomedical in South AfricaThe SINAPI Balloon meets a critical need in low-resource settings for an affordable easy to use fully assembled UBTWhen inserted into the uterus and filled with water the UBT exerts pressure that stops the bleeding within 5 to 15 minutesGravity-fed filling mechanism makes it easier amp faster Clinical trials to take place in 2016 to confirm safety

PATHrsquos low-cost UBT solution is promising for expanding access to life-saving PPH treatments

SIN

API b

iom

edic

alC

hristi

aan

van

Aard

t

copy Suellen Miller 2016

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 142: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

Synergy of TXAThrombinUBT

In porcine and murine testinggas generating microparticles of CaCO3 with TXA and thrombin self propel (through lateral propulsion buoyant rise and convection) to the bleeding site and function hemostatically to halt hemorrhage for traumatic and intraoperative bleeding

Model Concept would be toapply TXAThrombinCaCO3

to a UBT both to enhance drug delivery and apply physical Tamponade

Baylis et al Self-propelled particles that transport cargo through flowing blood and halt hemorrhageSci Adv 2015

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 143: OBSTETRIC PPH DRILL

The InPress

1 Seal created in birth canal2 Light vacuum force uterine

cavity 3 Uterus contracts and vessels

constricted

bull Immediately assess the efficacy of the treatmentbull Allows physician to accurately measure blood loss

Clinical Experience 10 patients in Jakarta IN

bull Hemorrhaging controlled lt2 minutesbull Device removal unremarkable no recurrence of bleedingbull CE Mark Application and Pre-IDE Submission to FDA

copy Suellen Miller 2016

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 144: OBSTETRIC PPH DRILL

The InPress How it Works

copy Suellen Miller 2016

>

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 145: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 146: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

Now about that dronehelliphellip

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 147: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

Health facility orders blood via mobile1 Drone can carry up to 10 kg

in 75 km radius3

Drone drops package at health facility in 15-45 min4

Zipline Rapid On-demand Aerial Delivery of BloodUterotonicsEmergency Supplies

dispatches a drone with package2

Ifakara Health Institute Tanzania amp Zipline Inc Pilot SLAB Grant

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 148: OBSTETRIC PPH DRILL

Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzania

copy Suellen Miller 2016

>

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 149: OBSTETRIC PPH DRILL

Conclusions Innovations Now and On the HorizonTriage

CradleMicrolife Traffic Light Vital Signs Device (SI) Early Warning Device can be used at any level of the health care system

Phone Pulse Oximeter (O2 Saturation)

Medications Carboprost TXANASG to decrease bleeding reverse shock stabilize women until definitive careAbdominal Compression Belt and Butterfly DeviceVariety of low cost intrauterine tamponade devices

DIY condom ESM-UBT Kit PATHSINAPI UBT UBC UBT + CaCO3TXAThrombin model

Drones and solar power (blood banks) may bring blood transfusion capacitydrugsLifeWraps closer to where women bleedcopy Suellen Miller 2016

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 150: OBSTETRIC PPH DRILL

Balloon Tamponade

bullA balloon (inflated with salinewater) exerts pressure to stop bleeding from within the uterus in 5-15 minsbullIs very effective (ge85) when uterotonics fail Can prevent need for laparotomy and hysterectomy (Reported success rates for the control and management of PPH with uterine tamponade are quite high and range between 70-100)bullEasy to usebullCan effectively be used in low resource settings

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 151: OBSTETRIC PPH DRILL

INDIAN INNOVATIONSDEBDAS BLOOD ESTIMATION SYSTEMCONDOM BALLON TAMPONADEUTERINE PACKING

copy Suellen Miller 2016

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 152: OBSTETRIC PPH DRILL

TAMPONADE TESTTherapeutic amp PrognosticFor severe PPH

Stomach balloonOesophagealballoon

Condous G Arulkumaran S etal Obstetrics amp Gynecology 2003

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 153: OBSTETRIC PPH DRILL

182

Balloon TamponadeAtonic PPH unresponsive to uterotonic drugsSimple inexpensive easy to use and effective Does not require special surgical skillsTemporarypermanent control of PPHBuys time to institute definitive treatmentBuys time to shift the patient

Condom tamponade

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 154: OBSTETRIC PPH DRILL

WHO RECOMMENDATIONS

1- Uterotonics Play a central role in treatment

2-uterine massage is advised

3- initial crystalloids recommended

4--use of Tx in refractory trauma bleeding

5-intrauterine balloon in refractory bleeding and when uterotonic not available

6-Bimanual uterine compression

7-external aortic compression

use of non pneumaticanti shock garments as temporizing measures

8- still not controlled then Uterine aa embolization should b considered

9-Despite all if not controlled then surgical intervention should b done without delay

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 155: OBSTETRIC PPH DRILL

Thank You

AcknowledgementsElizabeth Abu Haider PATHSINAPI UBT Mark Ansermino amp Beth Payne UBC Phone OximeterChristian Kastrup UBC UBTCaCO3TXAThrombin Jessie Becker Amy Degenkolb Jan Segnitz Nathan Bair Inpress DeviceVikram S Talaulikar amp Sabaratnam ArulkumaranSt Georgersquos Hospital Compression BeltAndrew Weeks Liverpool University ButterflyHannah Nathan Andrew Sheenan KCL CRADLEMicrolife VSAThomas Burke U of Mass ESM-UBTZac Mtema amp Godfrey Mbaruku IHIZipline TanzaniaNick Hu Zipline California USA

copy Suellen Miller 2016

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 156: OBSTETRIC PPH DRILL

copy Suellen Miller 2016

Thank You

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192
Page 157: OBSTETRIC PPH DRILL

MILLENIUM DEVELOPMENT GOALSAre nowSUSTAINABLE DEVELOPMENTAL GOALS

THANK YOU

  • OBSTETRIC DRILLS ndashPPH INDIA AUG 2016 6-11TH HYDERABADCHENNAIM
  • CONDUCTED BY
  • WELCOME
  • Slide 4
  • PPH Drill
  • PPH
  • Worldwide issue
  • Slide 8
  • Postpartum haemorrhage 1500 ml or more - all women who give bi
  • MDG - GOAL 5 IMPROVE MATERNAL HEALTH
  • Achieving Millennium Development Goal 5 is India serious Dile
  • MMR India over time
  • Slide 13
  • Maternal Mortality
  • Definitions
  • Causes of PPH the 4 Trsquos
  • Antenatal risk factors
  • Intrapartum risks
  • Third stage of Labour
  • Active vs Expectant Management
  • AMTSL WH
  • The GOLDEN HOUR
  • PPH Management
  • Confidential enquiries (UK)
  • Drugs
  • Uterotonic Drugs
  • Misoprostol FIGO
  • Fluids
  • IV Access
  • Pressure Bag
  • Other
  • Questions
  • Blood loss Estimation
  • The challenges
  • Visual Estimation of Blood Loss
  • Blood loss ndash quick quiz 1
  • Blood loss ndash quick quiz 1 (2)
  • Blood loss ndash quick quiz 2
  • Blood loss ndash quick quiz 2 (2)
  • Blood loss ndash quick quiz 3
  • Blood loss ndash quick quiz 3 (2)
  • Blood loss ndash quick quiz 4
  • Blood loss ndash quick quiz 4 (2)
  • Blood loss ndash quick quiz 5
  • Blood loss ndash quick quiz 5 (2)
  • BRASSS-V Drapetrade
  • Kellyrsquos Pad
  • Blood Mat
  • Local materials
  • PPH and shock
  • Monitoring MEWS
  • Slide 52
  • MEOWS Chart
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • The Value of MEWS charts
  • Questions (2)
  • Obstetric HDUICU
  • Rationale for an Obstetric HDU
  • Other drivers for change
  • Advantages of an Obstetric HDU
  • Disadvantages of an Obstetric HDU
  • Levels of Care
  • Slide 66
  • Graduated response to deterioration
  • Admissions to HDU
  • Minimum equipment requirements
  • Slide 70
  • Transfers out of HDU
  • Transfer of care
  • Discharges to ward
  • ISBAR tool
  • Slide 75
  • UK Obstetric HDU
  • Slide 77
  • Indian Obstetric HDU
  • Slide 79
  • Questions (3)
  • Transfer of Patient with PPH
  • When to transfer the patient with PPH
  • Prerequisites for Transfer
  • Referral Documents
  • On transfer
  • Slide 86
  • What is the NASG
  • Slide 88
  • Where in India
  • Clinical Trials Tertiary Level
  • Outcomes NASG Tertiary Level
  • Clinical Trials Primary Level
  • Pragmatic TrialImplementation Science 334 PHCs Rural Tanzani
  • Cost-Effective Analyses
  • Non-Pneumatic Anti Shock Garment (NASG)
  • NASG (Life Wrap)
  • How does NASG work
  • How does NASG work (2)
  • NASGrsquos Unique Role in Obstetric Hemorrhage and Hypovolemic Sho
  • About NASG
  • About NASG (2)
  • NASG (Life wrap)
  • Applying NASG
  • Applying NASG (2)
  • Applying NASG (3)
  • Applying NASG (4)
  • Vaginal Procedures with NASG in situ
  • Surgery with NASG in situ
  • Special situations
  • When to remove NASG
  • How to remove NASG
  • Do not remove NASG before all vital signs are restored Early r
  • Caution
  • Storing NASG
  • Relative contraindications
  • Principles to be observed
  • Advantages of NASG
  • World Scenario 2013
  • Slide 119
  • Slide 120
  • FIGO Guidelines
  • Slide 122
  • Partnership for Distribution in LMICEMECUN
  • Slide 124
  • Slide 125
  • Hemorrhage Etiologies UCSF
  • Safety
  • Conclusions
  • Slide 129
  • Slide 130
  • Slide 131
  • Innovations in Triage and Treatment of Obstetric Hemorrhage
  • Slide 133
  • Identify PPH
  • Be Ready for it all the time l
  • Slide 136
  • Slide 137
  • Slide 138
  • Slide 139
  • Slide 140
  • Slide 141
  • Teamwork
  • Slide 143
  • Low Tech Blood Loss Assessment
  • Slide 145
  • Slide 146
  • Slide 147
  • Slide 148
  • Slide 149
  • Slide 150
  • Slide 151
  • Slide 152
  • Slide 153
  • Slide 154
  • Slide 155
  • Vital Signs as Predictors
  • Slide 157
  • Suitable for Use in Low Resource Setting
  • Shock Index Thresholds HRSBP
  • KCL CRADLE Research
  • Phone Pulse Oximeter
  • Triage TRIGGER ACTION
  • LifeWrapNASG
  • Laerdal Compression Belt
  • Slide 165
  • Improving on Current Treatments
  • Slide 167
  • Slide 168
  • PATHSINAPI UBT KIT
  • Synergy of TXAThrombinUBT
  • The InPress
  • The InPress How it Works
  • Slide 173
  • Now about that dronehelliphellip
  • Zipline Rapid On-demand Aerial Delivery of BloodUterotonic
  • Zipline Delivers BloodMedicationsLifeWraps in Rwanda amp Tanzan
  • Conclusions Innovations Now and On the Horizon
  • Balloon Tamponade
  • Slide 179
  • INDIAN INNOVATIONS
  • Slide 181
  • Slide 182
  • Slide 183
  • Slide 184
  • Slide 185
  • Slide 186
  • Slide 187
  • Slide 188
  • Slide 189
  • Thank You
  • Slide 191
  • Slide 192

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