pph work shop part ii 10 2013

Dr. Mohamed El SherbinyMD Ob.& Gyn

Postpartum Hemorrhage (PPH)

Guidelines for Immediate Action “Part II ”

Damietta Specialized Hospital Workshop 2-11-2013

Sources of EvidencePubMed Cochrane library SOGC Clinical Practice Guideline No. 189,2007 Committee, Society for Maternal-Fetal

Medicine(SMFM), November 2010 RCOG Guideline 2005 & 2011( Placenta previa, & previa accreta) NICE Clinical Guideline, November 2011 (CS) Placenta Previa Accreta ACOG Committee 7-2012Damietta Governorate experience (FIGO 10- 2012 )UpToDate, Reaink , Augest 2013

What Is The Next Step if Balloon Tamponade Fails ?

The following may be attempted, depending on clinical circumstances and available expertise:Haemostatic brace suturing (B-Lynch or

modified compression sutures)Bilateral ligation of uterine arteriesBilateral ligation of internal iliac (hypogastric)

arteriesSelective arterial embolisation

RCOG Guideline PPH No.52 May 2009 Grade C4

Compression sutures, may be

attempted as a first intervention, and if

these fail, then uterine, utero-ovarian

and hypogastric vessel ligation may be

tried.

If Balloon Tamponade Fails

Stepwise uterine artery ligation (SUAL)is the first-line surgical approach . If bleeding is not controlled by SUAL or no available expert to perform it, shift to use of uterine compression (Brace) suture technique is the second step.

Jacob , UpToDate Aug. 2013 Grade C

If Balloon Tamponade Fails

Intractable Atonic PPH Algorithm Vaginal delivery

Failed

Expertise Stepwise Uterine Arteries Ligation

(SUAL)

Balloon Tamponade

Laparotomy

± Non-pneumatic anti-shock garment if available

Failed : ±Internal iliac ligation -Hysterectomy

Low experience or Failed SUAL : B-Lynch/Hayman ± sandwich

Uterine Compression (Brace) Sutures

B-Lynch suture 1997Hayman suture 2002Sandwich 2007

(combined with Balloon tamponade)

Test For Uterine Compression Sutures

An assistant stands between the patient’s legsto determine and extent of the bleeding. The uterus is then exteriorized and bimanual compression performed. • The Test is positive if the bleeding stops and the compression suture will work and stop thebleeding.

B-Lynch Suture

AnteriorPosterior

B-Lynch Suture

B-Lynch Suture

Monocryl No.1 mounted on 90-cm curved blunt needle or other rapidly absorbable sutures

B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd Ed.2012

It is recommended that a laminated diagram of the brace technique be kept in theatre.

RCOG Guideline PPH No.52 May 2009 Grade C

B-Lynch Technique

Simple, effective (91-99%) and cost-saving

Fertility preserved and proven

Mortality avoided

World-wide application(1300 cases) and

successful (only 19 failures reports.

The B-Lynch surgical technique

B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd Ed.2012

Hayman Compression Suture

Hayman et al Obst. Gynec. 2002,99;3;502-6

A number 2 Vicryl or Dexon suture on a straight, blunt needle is used to transfix the uterus from front to back, just above the reflection of the bladder and is then tied at the fundus of the uterus.

This can be done as one suture on each

side of the uterus, or more than one suture if

the uterus is particularly broad,

Hayman Uterine Compression SutureAdvantage Uterine cavity not opened Probably quicker and easier to applyDisadvantage Uterine cavity not explored under direct vision No feed-back data on fertility outcome Morbidity feed-back data limited Unequal tension leads may to segmented Ischemia secondary to slippage of suture –

‘shouldering’ with venous obstructionB-Lynch & Shah, A Comprehensive Text Book of PPH 2nd Ed.2012

Hayman Uterine Compression SutureEl Sherbiny

Combination of External Compression & Internal Tamponade

“ Uterine Sandwich” Indicated for patients with persistent bleeding from uterine atony refractory tomedical therapy and has negative or unsatisfactory compression suture test . The balloon is inflated with median volume of (range 60 to 250 mL) to avoid "undue blanching

at the compression suture sites," which might lead to uterine laceration or necrosis

Bakri ,UpToDate,Mar.,2013

Intrauterine balloon (Bakri) in combination with a B-Lynch uterine compression suture

Nelson &O'Brien , Am J Obstet Gynecol. 2007;196(5):

Diemert et al.Am J Obstet Gynecol. 2012;206(1):65.e1

Uterine Sandwich

Bakri balloon tamponade combining with Hayman external compression suture .

Yoong et al. Acta Obstetricia et Gynecologica Scandinavica , 91 (2012) 147–1512011

Uterine Sandwich

Nelson &O'Brien , Am J Obstet Gynecol. 2007;196(5):

Hayman

Uterine Sandwich

Yoong et al. Acta Obstetricia et Gynecologica Scandinavica , 91 (2012) 147–1512011

Stepwise

Devascularization

Stepwise Uterine DevascularizationThis technique entails five successive steps, so if bleeding is not controlled by one step the next step is taken until bleeding stops. The steps are (1)unilateral uterine vessel ligation, (2) bilateral uterine vessel ligation(3) low uterine vessel ligation(4) unilateral ovarian vessel ligation (5) bilateral ovarian vessel ligation.

AbdRabbo ,Am J Obstet Gynecol. 1994 Sep;171(3):694-700 (103 patients intractable PPHg result 100% )

Advantages over internal iliac ligation: Easier dissection.Lower complication rates.More distal occlusion of arterial supply with less potential for rebleeding because of collateralsHigh reported rates of success in controlling haemorrhaging.

(SOGC ) Clinical Practice Guidelines 2000

Stepwise Uterine Devascularization

12

45

3


1

3

2


Each suture: Starts in a vascular

area just lateral to the outer margin

of the uterus, then encompasses

2cm of uterine walls medially

encircling the blood vessels within it.

PPH After

CS35

PPH After CS : Causes 1- uterine atony 2-Placent previa &placenta accreta/ increta/percreta 3- Trauma: bleeding from the uterine incision or extensions of this incision or bleeding from vaginal or cervical tears or uterine rupture 4- Retained placenta

36

PPH After CS : ManagementUterine atony: Fundal massage and uterotonic drugs (including intrauterine injection ) Truma:Inspection for and repair of lacerations and incisional bleeding. The angles of a transverse incision should be clearly visualized and any retracted vesselsare ligated. The ipsilateral ureter should be identified before bleeding is controlled. 37

Intractable Atonic PPH Algorithm

Cesarean Section

Expertise Stepwise Uterine

Arteries Ligation(SUAL)

Low experience or Failed SUAL: B-Lynch/Hayman

± sandwich

Failed : ± Internal iliac ligation Hysterectomy

Excluding the other 3 Ts ( Extension , C. tears ,PP accreta

Upper S Atony

Intractable Atonic PPH Algorithm

Cesarean Section

Expertise Stepwise Uterine Arteries LIG. (± Prophylactic)

Total Hysterectomy

Excluding the other 3 Ts ( U .S.atony , Trauma or thrombin

Lower S Atony

Major P. Previa or Focal PP accreta

Low Experience

Balloon Tapenade Dissectible Bladder

Longitudinal Lateral .Uterine Sutures

Non -Dissectible Bladder

Management of

Placenta Previa Accreta

“The New Nightmare”

Morbid Adherent Placenta :

Accreta 79%

Increta 14%

Percreta 7%

79%

14% 7%

Attach to the myomet.

penetrate to serosa invade into the

myometrium

UpToDate , Resink , Aug 2013

1-Placenta previa : 9.3% Vs 1/22,154 without PP

2-Uterine scare: 29% with placenta over the scar

Versus 6.5% not over the scar

3-Raised Maternal Age

The most important and the commonest

risk factor is placenta previa after a prior CS.

Silver et al.. Obstet Gynecol 2006; 107:1226–1232. Stafford I, et alContemp Obstet Gynecol 2008;82-53:76

Risk Factors For placenta Accreta

Ferrazzani et al,. Fetal Diagnosis and Therapy; 2009. 25:400–403.

Women with placenta accreta/percreta are

at very high risk of major PPH.

If placenta accreta or percreta is diagnosed

antenatally, there should be consultant-led

multidisciplinary planning for delivery.

RCOG Guideline PPH No.52 May 2009 (Grade C)

Complication of 109 Cases Of Placenta Percreta

Bl.transfusion of > 10 units 40%Maternal death 7%Infection 29%Perinatal death 9%ureteral ligation 5%Fistula formation 5%Uterine rupture 3%.

O'Brien,. Am J Obstet Gynecol 1996; 175:1632.22.

Progressive increase

1950 : 1/30,000

1980s : 1 /2500

2002 : 1 / 535

2006 : 1/210

An increase of 142 Fold !! mainly due to the marked ↑ in CS rate worldwide .

The incidence of Morbid Adherent Placenta

Stafford & Belfort, Contemp Ob/Gyn April:77, 2008 UpToDate , Resink , Aug 2013

Frequency of Placenta Accreta According To Number of CS Deliveries And Presence

of Placenta PreviaCesareandelivery

Placentaprevia

NoPlacenta previa

First (primary)3.3 0.03Second11 0.2Third40 0.1 Fourth61 0.8Fifth670.8≥ Sixth674.7

SMFM. Placenta accreta. Am J Obstet Gynecol 2010. UpToDate , Resink , Aug 2013

Prenatal detection of placenta

previa accreta is associated with

decreased in:

Feto-maternal morbidity &

Feto-maternal mortality

Warshak., et al Obstet Gynecol 2010;115:65–9

CHOU et al Ultrasound Obstet Gynecol 2002; 15: 28–35.

Diagnosis of placenta accreta before

delivery allows multidisciplinary

planning in an attempt to minimize

potential maternal or neonatal

morbidity and mortality.

ACOG Committee 7-2012

Diagnosis of Placenta

Previa Accreta (PPA)

Clinical Manifestations of Placenta Accreta

AP Hemorrhage :In focal accreta Interapartum hemorrhage : Profuse,

life-threatening at the time of manual placental separation

The usual first manifestation of diffuse accreta . Hematuria :During pregnancy :With bladder invasion.

RCOG Guideline PP PPA No. 27 October 2005

SOGC Clinical Practice Guideline No. 189,2007

RCOG Guideline PPH No.52 ,2009

RCOG Guideline PP PPA No. 27 , 2011

ACOG Committee 7-2012

Recommendations For Prenatal Diagnosis of PP Accreta

Early counselingProper Decision :1-Conservative Vs hysterectomy

2-Elective rather than emergency

Preoperative preparation & operative plannining

PP. With previous CS are at high risk of

having a morbidly adherent placenta and

should have been imaged antenatally.

Colour flow Doppler U/S should be

performed .

PP. With previous CS

RCOG Guideline No. 27 October 2005 Grade C

Women with a placenta previa and a prior CS

are at high risk for placenta accreta.

If there is imaging evidence of pathological

adherence of the placenta, delivery should be

planned in an appropriate setting with

adequate resources.

PP. With Previous CS

SOGC CLINICAL PRACTICE GUIDELINE 2007(II-2B)

All women who have had a previous CS must have their placental site determined by U/S.

RCOG Guideline PPH No.52 May 2009 (Grade C)

Placenta previa With Previous CS

Antenatal sonographic imaging can be complemented by MRI in equivocal cases

RCOG Green-top Guideline PP PPA No. 27 2011

Diagnosis Of A Morbidly Adherent Placenta

Woman and her family can be counseled early

Ghourab et al .Ann Saudi Med 2000;20:382–5.Dashe et al. Obstet Gynecol 2002;99:692–7.

Evidencelevel III

U/S at 20-24 weeks: Why?

Placental migration is less likely if

There has been a previous CS.

Diagnostic Modalities of The Morbidly Adherent PlacentaUltrasound

Gray scale U/S Colour flow Doppler 3D power Doppler

MRI

Ultrasound is the most useful modalities for evaluating placental position and implantation

Resnilk ,UpToDate , Aug 2013ACOG Committee 7-2012

A Non Adherent Placenta Previa

1-Normal subplacental Hypoechoic Zone(myometrial vasculature )

2-Normal posterior bladder wall

3-Normal placental vascular pattern

Gray scale U/S

1-Normal subplacental Hypoechoic Zone (myometrial vasculature )

2-Normal posterior bladder wall

31-Normal placental vascular pattern

A Non Adherent Placenta Previa

Greyscale : Loss of the retroplacental sonolucent zoneIrregular retroplacental sonolucent zoneThinning or disruption of the hyperechoic

serosa–bladder interface. Abnormal placental lacunae.Presence of focal exophytic masses

invading the urinary bladder

RCOG Green-top Guideline No. 27 2011

What Are The U/S Criteria for Diagnosis of P Accreta?

A Morbidly Adherent Placenta Previa

1-Loss or Irregularity of the retroplacental sonolucent zone

2- Thinning or disruption of the hyperechoic serosa–bladder interface

3-Vascular lacunae"swiss chess appearance”+ve Pred.v :95%

A Morbidly Adherent Placenta

Abnormal placental lacunae. "swiss cheese appearance”

Positive perdictive value +ve Pred.v :95%

A Morbidly Adherent Placenta

Turbulence

Diffuse or focal lacunar flow

Vascular lakes with turbulent flow (peak

systolic velocity over 15 cm/s)

Hypervascularity of serosa–bladder

interface

Markedly dilated vessels over peripheral

subplacental zone.


What Are The Colour Doppler Criteria for Diagnosis of PPA ?

Diffuse or focal lacunar flow

Hypervascularity of serosa–bladder interface

Markedly dilated vessels over peripheral subplacental zone

Multiple large vessels extending through the bladder wall of PP. percreta.

At least one diagnostic criterion was present.Multiple diagnostic criteria : Higher prediction

Diagnostic Performance of U/S Modalities

RCOG Green-top Guideline No. 27 January 2011

Shih et al . Ultrasound Obstet Gynecol,203-33:193 ;2009.

Overall, grayscale U/S is sufficient to diagnose

PPA , with a sensitivity of 77–87%, specificity of

96–98%, a positive predictive value of 65–93%).

The use of power Doppler, color Doppler, or 3D

imaging does not significantly improve the

diagnostic sensitivity compared with that

achieved by grayscale U/S aloneACOG Committee 7-2012

Positive Doppler data confirm the diagnosis

It is still debated. Sensitivity & specificity are comparable with U/SMRI was better at detecting the depth of infiltration or when U/S findings are inconclusiveThe main MRI features of placenta accreta : ● Uterine bulging● Heterogeneous signal intensity within the placenta● Dark intraplacental bands on t2-weighted imaging.

The Role Of MRI In Diagnosing PPA


Sagittal T2WI MR of a placenta percreta :placental invasion into the bladder

Prenatal Care Correction of iron deficiency anemia, if present Antenatal corticosteroids between 23 and 34 weeks of gestation for pregnancies at increased risk of delivery within seven days (eg, antepartum bleeding)Anti-D immune globulin if vaginal bleeding occurs and the patient is Rh(D)-negativeSerial U/S assessment of the placenta is generally not useful after the diagnosis of accreta, increta, or percreta has been made

Resnilk ,UpToDate , Aug 2013

Decision MakingU/S Guided

Counseling & ConsentAny woman with suspected placenta praevia accreta should be counseled clearly in a consent form.

This should include: The anticipated skin and uterine incisions Whether conservative management or proceeding straight to hysterectomy if accreta is confirmed at surgery

RCOG Green top Guideline No. 27 January 2011

1- Consultant obstetrician planned and

directly supervising delivery

2- Consultant anaesthetist planned and

directly supervising anaesthetic at delivery

3-Blood and blood products available

4- Multidisciplinary involvement in pre-op planning

What Preparations Should Be Made Before Surgery?


At least two large bore intravenous catheters should be placed.

A 3-way Foley catheter and ureteral stents should be available in case they are needed to assess integrity of the urinary tract.

Balloon catheterization of the internal iliac arteries may resulted in significantly less blood loss, lower blood transfusion requirements, and shorter duration of surgery. Others investigator have not documented significant benefits


Resnilk ,UpToDate , Aug 2013

5-Discussion and consent includes possible

interventions (Such as hysterectomy,

leaving the placenta in place, Cell salvage

and intervention radiology)

6-Local availability of a level 2 critical care bed.



At what gestation should elective delivery occur?

Elective CS delivery in asymptomatic women is not recommended before 36–37 weeks GA for suspected placenta accreta.

RCOG Green top Guideline No. 27 January 2011

A course of corticosteroid at 34 ws gestation and deliver after 48 hours. This is supported by reported outcomes, as well as a decision analysis

UpTODate ,Resink, Aug 2013ACOG Committee 7- 2012

Opening the uterus at a site distant from

the placenta, and delivering the baby

without disturbing the placenta.

Going straight through the placenta to

achieve delivery is associated with more

bleeding and a high chance of

hysterectomy and should be avoided.RCOG Green-top Guideline No. 27 2011

What Surgical Approach Should Be Used For Suspected PPA ?

Grade C/D

Guided U/S

Opening the uterus at a site distant from the placenta

UpTODate ,Resink, Aug 2013

Preoperative or intraoperative

sonographic localization of the

placental edge is helpful for

determining the best position for the

hysterotomy incision


Strong evidence of of diffuse PP accreta

Focal or No strong evidence of of PPevia accreta

No incision at the placental site (USCS)

Don’t separate the placenta even if the uterus is conserved

Separation of the placenta may be allowed if the uterus is to be conserved

Focal PP Accreta

Focal accreta : TAH is recommended If future fertility is strongly desired : Conservatism

Separation of the placenta may be allowed if the uterus is

to be conserved

Transient Packing &Stepwise Uterine A ligation 1&2

Stepwise Longitudinal

lateral sutures Total

Hysterectomy

No Strong fertility need

Fertility need

Focal or Unexpected PP Accreta

Faild

Non Dissectible Bladder

If still bleeding (50%)

Separation of the Placenta

Dissectible Bladder

Balloon inverted Glove Tamponade

??Opening the bladder

Mohamed El Sherbiny MD Ob.& Gyn. Damietta Egypt

Conservative Management of

Placenta Previa-Accreta by

Prophylactic Uterine Arteries

Ligation and Stepwise Vertical

Compression Sutures.

XX FIGO World Congress October 2012

MaterialsThis protocol was followed in 13 womenundergoing CS for placenta previa with focal accreta suspected or diagnosed byultrasound, color and power Doppler studies.All patients were recruited from ultrasound scanned women with previous CS

MaterialsThe exclusion criteria were:1-Posterior placenta previa2-Placental implantation away from the

scar3- Diffuse PP accreta that either :a-Wide area of accreta orB-Deep penetration to the bladder

Setting

Damietta General Hospital

Damietta Specialized Hospital and

Dr. El.Sherbiny Hospital

Between April 2004 and December 2011.

MethodsAfter delivery of the fetus, the uterine

cavity was temporarily packed by gauze

till prophylactic bilateral double

ligation of the uterine arteries is

performed, then the placenta was

removed.

Uterine cavity is

temporarily packed by

gauze

1

2


Prophylactic bilateral

double ligation of the

uterine arteries

Prophylactic bilateral

double ligation of the

uterine arteries

Stepwise Longitudinal Lateral Sutures

Anatomy: Branches of the uterine arteries pass transversely to

anastomose with the opposite side

Tow lines of longitudinal number 1 chromic catgut sutures are taken through anterior and posterior uterine wall perpendicular to the vessels and 2 cm medial to the outer borders of the lower uterine segment .

Stepwise Longitudinal Lateral Uterine Sutures: First Step


1 1

Stepwise Longitudinal Lateral Uterine Sutures: Second Step

If still there is bleeding, other 2 medial similar lines of number 1 catgut sutures are taken leaving free central area.

1 12 2


Longitudinal lateral sutures at the site of bleeding

suturing both uterine walls

RقESULTS

E S U L T S

Suspected Focal PPA (n:13)

10 cases evidence of

focal accreta

Double UAs Ligation

and removal of the Placenta

2 cases

No evidence of accreta

1 cases evidence of Diffuse accreta

Treated outside this protocol by leaving the placenta in situ &closing the uterus

Compression sutures protocol

All successful

1 cases

Bleeding stopped

One cases

Need Compress

-ion sutures protocol

Results All 10 women with focal

accreta later resumed normal menstrual flow.

Results All of them underwent diagnostic

office hysteroscopy 2 months after thesurgery, nine of them showed normaluterine cavity .

Only one had mild synechia and wascorrected in the same hysteroscopic setting

Results The mean surgical time was

50 minutes and The mean transfused blood volume was 750 mL.

Conclusion Placental site bleeding due to adherent focal placenta accreta can be safely controlled by prophylactic doublebilateral uterine artery ligationfollowed by stepwise vertical compression sutures in women who desire preservation of fertility.

Balloon Tamponade After CSBalloon catheters have been used with variable success to control bleeding after CS delivery with : Placenta Previa Or Adherent Placenta

Frenzel et al ,Br J Obstet Gynaecol 2005;112: 7-676

Bakri et al . Int J Gynaecol Obstet 2001;74:139–42

Vitthala et al. Aust N Z J Obstet Gynaecol. 2009;49(2):191.

)Success R.: 56%(

Ishii et al , J. Obstet. Gynaecol. Res. January 2012 ,Vol. 38, No. 1: 102–107,

Inverted finger knotted glove

Inserting the end of the 2 catheters through the open uterine incision to the cervix and then into the vagina

After closure, assistants infate the balloon with sterile saline while inspecting the uterus from above

Diffuse

PP Accreta

Strong evidence of diffuse PP accreta1 -T AH is recommended 2- ± Conservatism (Placenta left "in situ") Only if Hemodynamic stabilityNormal coagulation Strong desire for fertility Accept the risks involved

No incision at the placental site (USCS)No separate the placenta even if the uterus

is planned to be conserved ACOG Committee 7- 2012

1-No further Treatment (Expectant)

2- Uterine artery embolization

3-Methotrexate therapy

4-Hemostatic sutures

5-Arterial ligation

6- Balloon tamponade

Placenta Left "in Situ “What is the Further Treatment ?


Risks of Uterine Conservation With the Placenta Left in Situ


Severe vaginal bleeding: 53 %

Sepsis: 6 %

Secondary hysterectomy: 20% percent (range 6

to 31 %)

Death: 0.3 % (range 0 to 4 %)

Subsequent pregnancy: 67 % (range 15 to 73 %)

Cunningham et al, Williams Obstetrics, 23rd edit. 2010

Elective Versus Emergency Peripartum Hysterectomy

ComplicationsElective(n=345)

Emergency(n=644)

Transfusion 28%83%Urinary T.injuries

1.8%6.5%

Surgical infection

21%25%

Death 0%1.4%Briery (2007), Castaneda (2000), Glaze (2008), Kastner (2002), Kwee (2006),

Sakse (2008

Conservative management of

placenta accreta when the woman is

already bleeding is unlikely to be

successful and risks wasting

valuable time..


What Surgical Approach Should Be Used For PPA Already in Bleeding?

GPP

Peripartum Hysterectomy

Key Points

Peripartum Hysterectomy

Abnormal placentation is the main indication for peripartum hysterectomy.

Glaze et al Obstet Gynecol. 2008 Mar; 111(3):732-8 ( 87 case 8 years Canadian) LEVEL OF EVIDENCE: III.

A vertical skin incision is optimal, Pfannenstiel incision is not

sufficient.

Classical CS-Hysterectomy

After delivery of the infant, the cord is cut, the uterine

incision is oversewn circumferentially to decrease blood

loss, and hysterectomy is performed.

Should be simple , rapid, with minimal dead space and raw

surfaces (fear of coagulopathy).

Drainage

Hysterectomy: The Technique

Peripartum Hysterectomy The hysterectomy Should be Total

It should be simple , rapid, with minimal dead

space and raw surfaces (fear of coagulopathy).

Tow to three drainages

Inadequate exposure or traction may lead to vascular or ureteral injury

Balfour abdominal retractor



If the bladder does not dissected easily, it should be opened at the dome. Palpation and inspection of the posterior bladder from the interior makes it easier to find the dissection plane

Consultation with a gynecologic oncologist or urologist is warranted if the surgeon is not familiar with bladder surgery.

Post Hysterectomy Bleeding

• Diffuse post hysterectomy bleeding may be controlled by abdominal packing to allow time for normalization of the woman’s haemodynamic and coagulation status. (II-3)

• The pack composed of gauze in a sterile plastic bag brought out through the vagina and placed under tension. This pack is also known as a parachute, mushroom, or umbrella pack.

S O G C C L I N I C A L P R AC T I C E G U I D E L I N E S 2000 II

Assembly of a pelvic pressure pack to control hemorrhage. A sterile x-

ray cassette cover drape (plastic bag) is filled with gauze rolls tied

end-to-end. The length of gauze is then folded into a ball (A) and placed

within the cassette bag in such a way that the gauze can be unwound

eventually with traction on the tail (D). Intravenous tubing (E) is tied to the exiting part of the neck (C) and

connected to a 1-liter bag (G). Once in place, the gauze pack (A) fills the

pelvis to tamponade vessels and the narrow upper neck (B) passes to exit the vagina (C). The IV bag is

suspended off the foot of the bed to sustain pressure of the gauze pack

on bleeding sites.

pelvic pressure pack, as constructed from an X-ray cassette drape, sterile gauze rolls, and an intravenous infusion set-up

the pelvic pressure pack in situ

Thank You

Thank You

pph work shop part ii 10 2013

Health & Medicine