GC DI RENZO, MD, PHD, FRCOG, FACOGPERUGIA, ITALY

MANAGEMENT OF POST-PARTUM HEMORRHAGE

Why focus on preventing

post-partum hemorrhage?

Haemorrhage is the largest direct cause of maternal death

PPH is mostly unpredictable Most PPH is caused by uterine atony Evidence-based, feasible, low-cost

interventions exist Active management at the third stage

of labour can prevent 60% of PPH

Difficulties associated with comparing

post-partum hemorrhage studies

Method to determine blood loss – Visual underestimation 70–80%

Conduct during third stage of labour Confounding factors in

epidemiological studies 58% of trials do not report their

definition of PPH

Maternal Health:some ( underestimated) statistics

180–200 millions pregnancies per year 75 millions unwanted pregnancies 50 millions induced abortions 20 millions unsafe abortions 358,000 maternal deaths (1000 per day) 1 death every 1,5 min 20 maternal morbidities per minute 10-15 millions disabilities each year

WHO, 2010

Every Minute...

Maternal Death Clock 380 women become pregnant 190 women face unplanned or

unwanted pregnancy 110 women experience a

pregnancy related complication 40 women have an unsafe

abortion 1 woman dies from a pregnancy-

related complication 20 women suffer of a disabilty

related to childbirth

WHO, 2010

About two thirds of maternal deaths are About two thirds of maternal deaths are due todue to

Anemia-HemorrhageObstructed deliveryEclampsiaSepsisUnsafe abortion

They can be treated by a

health professional

Causes of maternal mortality

Maternal mortality from post-partum hemorrhage in

the UK

88% received substandard careHall M. 2004; Why mothers die (2000–2002) CEMACH.

0

1

2

3

4

5

6

85–87 88–90 91–93 94–96 97–99 00–02

Mat

erna

l mor

talit

y ra

te/m

illio

n

Year

Sub-standard care Organisational problems

– Inappropriate booking– Inadequate blood transfusion– Intensive care facilities

Poor quality of resuscitation– Inadequate transfusion– Blood products

Equipment failure– Malfunctioning of specimen transport system

Failure to recognise or treat antenatal medical conditions– Inherited bleeding disorders

Failure of senior staff to attend Concerns about the quality of surgical treatment given

Hall M. 2004; Why mothers die (2000–2002) CEMACH.

As with many problems, there seems

to be two different kinds of emergencies...

...depending on whether the patient is in a

developed or undeveloped country

Developed countriesSequence: Diagnosis PPH

Protocol-management

Treatment

Success (>98%)

Undeveloped countries• Sequence: • Diagnosis PPH (?)

• Emergency (?)

• Transfer (?)

• Centre (?)

• Treatment (?)

• Success (<60%)

Post-partum hemorrhage

Equal opportunityoccurrence

2/3 no risk factors

Not equalopportunity

killer

Poor Malnourished Unhealthy

What is post-partum hemorrhage?

Excess blood loss after the birth of a baby  

PPH >500 ml (3.5–30%)

Severe PPH >1000 ml (1.5–5.0%)

Immediate PPH: – Onset within 24 h of birth

PPH late: – Onset after 24 h of birth

These definitions are not accepted by all!!

One of the main One of the main problem……problem……

UNDERESTIMATION OF BLOOD UNDERESTIMATION OF BLOOD LOSSLOSS

Methods used to diagnose post-partum hemorrhage

Clinical methods– Physiological response to blood loss

Quantitative methods– Visual assessment– Direct collection of blood into bedpan or plastic

bags– Gravimetric method– Changes in hematocrit and haemoglobin– Others

Plasma volume Tagged erythrocytes

Estimated blood loss

Prasertcharoensuk et al. IJGO 2000

0

5

10

15

20

25

30

>500 ml >1,000 ml

Visual

Measured

Est

imat

ed b

lood

loss

(%

)

Calibrated bagCalibrated bag(Brass-V)(Brass-V)

Risk factors

1. placenta previa with or without previous uterine surgery.

2. previous myomectomy.3. previous cesarean delivery. 4. Asherman's syndrome. (treated

surgically)5. submucous leiomyomata. 6. maternal age of 36 years and

older.

Risk factors (multivariable analysis)

Retained placenta, OR=3.5 Failure to progress to second stage, OR=3.4 Placenta accreta, OR=3.3 Lacerations, OR=2.4 Instrumental delivery, OR=2.3 Newborn large for gestational age, OR=1.9 Hypertensive disorders, OR=1.7 Induction of labour, OR=1.4 Augmentation of labour with oxytocin, OR=1.4

Sheiner E, et al. J Matern Fetal Neonatal Med 2005.

The risk of placenta previa was 0.26% with an unscarred uterus and increased almost linearly with the number of prior cesarean sections to 10% in patients with four or more.With a placenta previa and one previous cesarean section, the risk of placenta accreta was 24%; this risk continued to increase to 67% (two of three) with a placenta previa and four or more cesarean sections.

Obstetrics & Gynecology 1985;66:89-92 Placenta Previa/Accreta and Prior Cesarean SectionSTEVEN L. CLARK Et al

Ch. B- Lynch

1° ed 2006

2° ed 2012

MANAGEMENT

( FIGO 2009 – Cape Town)

COMPREHENSIVECOMPREHENSIVE

MedicalMedical

Surgical

Mechanical

Joint statement management of the third stage

of labour to prevent post-partum hemorrhage

Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony– Consists of interventions designed to facilitate the delivery of

the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony. The usual components include: Administration of uterotonic agents Controlled cord traction Uterine massage after delivery of the placenta, as

appropriate Every attendant at birth needs to have the knowledge, skills

and critical judgment needed to carry out active management of the third stage of labour and access to needed supplies and equipment

Maternal outcomes of active management

trials

McCormick et al, IJGO 2002

0

10

20

30

Transfusion Prolonged third stage

Therapeuticuterotonic

drugs

Lowhaemoglobin

Retainedplacenta

Pat

ien

ts (

%)

Active managementPhysiological management

POSTPARTUM HEMORRHAGE

need of “ action” in the “golden hour”in order to increase the probability of patient survival:

The mnemonic The mnemonic HAEMOSTASISHAEMOSTASIS can assist in remembering can assist in remembering the sequence of events to confrontthe sequence of events to confront

HHAEMOSTASISAEMOSTASIS

H: Get HELP

HHAAEMOSTASISEMOSTASISA: evaluate the vital parameters of the patient and the amount of blood loss

HAHAEEMOSTASISMOSTASISE: identify the cause (ethiology) and the appropriate treatment (4T)

ToneTissue

Trauma Trombin

Causes of post-partum hemorrhage (4T)

Anderson et al. Am Fam Physician 2007.

CAUSE

(70%)

(19%) (10%)

(1%)

TONE

TISSUE

THROMBIN

TRAUMA

RISK FACTORSEtiology Process Clinical Risk Factors

Tone Overdistended Uterus Polyhydramnios, Multiple GestationMacrosomia

Uterine Muscle Fatigue Rapid Labor, Prolonged LaborHigh Parity

Intra Amniotic Infection Fever, Prolonged ROM

Functional/Anatomic Distortion of the Uterus

Fibroid UterusPlacenta PreviaUterine Anomalies

Tissue Retained ProductsAbnormal Placenta

Incomplete Placenta at DeliveryPrevious Uterine ScarHigh Parity

Retained Blood Clots Atonic Uterus

Trauma Lacerations Precipitous or Operative Delivery

Extensions at C/S Malposition, Deep Engagement

Uterine Rupture Previous Uterine Surgery

Uterine Inversion High Parity, Fundal Placenta

Thrombin Pre-existing Coagulopaties, Liver Disease

Acquired in Pregnancy ITP, DIC

Therapeutic Anti-coag History of DVT or PE

HAEMHAEMOOSTASISSTASISO: proceed with oxytocin infusion, prostaglandins ( via rectal, intramuscolar, IV, intramyometrial)

(off label)

First line

Second line

Third line

Drugs to prevent and treat uterine atony

•Prophylactic syntometrine versus oxytocin•Prophylactic use of oxytocin•Carbetocin•Injectable prostaglandins•Misoprostol

• Dioscorides: cyclamen, 100 AD

• Ergot (Claviceps purpurea), 1582 AD

Ancient Oxytocics

40

• Egyptian Papyrus Ebers, 1500 BC

contract uterus: speed birth, stem haemorrhage

hemp in honey

celery in milk

juniper berries

fly excrement (in many ancient pharmacopoeias)

• Nobel prize in chemistry 1955

sulphur compounds of high importance

first synthesis of a polypeptide hormone

T Reinheimer, 2009

1953: Synthesis of Oxytocin

Vincent du Vigneaud

– American biochemist

– discovery, isolation, and synthesis

together with ADH/vasopressin

41

The Nobel Foundation 1955http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.gif

T Reinheimer, 2009

Oxytocin Today

– oxytocin (sometimes combined with ergometrin)

42

Martindale 2008http://www.appdrugs.com/ProdJPGs/OxytocinLg.jpg

• Labour induction/augmentation

• Prophylaxis and Treatment of Postpartum haemorrhage

retained placenta: umbilical vein injection

milk ejection/lactation: oxytocin nasal spray

T Reinheimer, 2009

Oxytocin Agonists

Carbetocin (DURATOCIN, PABAL)

– long-acting synthetic analogue

– indication: prevention of uterine atony

– veterinary medicine

43

Pritt et al. 2004, Manning et al. 2008http://www.bcnpeptides.com/images/products/carbetocina.jpg

WO/2003/000692, US/20070117794

• Non-peptide agonists

patented for erectile dysfunction

WAY-262464: patented for anxiety, schizophrenia

• 30 women with elective caesarean section

• 5 u of oxytocin either as a bolus injection or an infusion over 5 min

• Heart rate and intra-arterial blood pressure recorded every 5 s

Mean arterial pressure (MAP) changes with oxytocin

Mea

n ch

ange

of M

AP

(m

mH

g)

Study period (s)

Thomas JS, et al. Br J Anaesth 2007

Carbetocin – Pharmacodynamics

Oxytocin Carbetocin

N=240Study design: Prospective double-blind randomized controlled studyDrugs: Carbetocin 100 µg i.m. vs. syntometrine (5 IU of oxytocin and0.5 mg of ergometrine) i.m.Primary outcome: postpartum hemorrhage requiring additional uterotonic therapySecondary outcome: incidences of postpartum hemorrhage (>500 ml) and severe postpartum hemorrhage (>1,000 ml) as well as adverse effects profile

Authors Conclusion:

A single dose of intramuscular carbetocin

100µg may be more effective as compared to a single intramuscular dose of syntometrine (5 IU of oxytocin and 0.5 mg of ergometrine) in reducing postpartum blood loss

Lower incidence of adverse effects.

N=377Study design: double-blind randomised single centre studyDrugs: carbetocin 100 µg or oxytocin 5 IU, both i.v.Primary outcome: Need of additional pharmacological oxytocic interventions.Secondary outcomes: Estimated blood loss, difference in preoperative and postoperative haemoglobin, incidence of blood transfusion and adverse effects

Authors conclusion:

Carbetocin reduces the use of additional oxytocics following caesarean section when compared with the licensed dose of oxytocin (5 IU)

StudyCarbetocin

n/NOxytocin

n/NRR (Fixed)

95% CIWeight

(%)RR (Fixed)

95% CI

01 Caesarean delivery

Boucher 1998 0/29 3/28 100 0.14 (0.01, 2.56)

Dansereau 1999 15/317 32/318 900 0.47 (0.26, 0.85)

Subtotal (95% CI)

346 346 100.0 0.44 (0.25, 0.78)

Total events: 15 (carbetocin), 35 (oxytocin)Test for heterogeneity chi-square=0.66; df=1; p=0.42; I2=0.0% Test for overall effect z=2.81; p=0.005

02 Vaginal delivery

Boucher 2004 12/83 12/77 100.0 0.93 (0.44, 1.94)

Subtotal (95% CI)

83 77 100.0 0.93 (0.44, 1.94)

Total events: 12 (carbetocin), 12 (oxytocin)Test for heterogeneity not applicableTest for overall effect z=0.20; p=0.8

Carbetocin versus oxytocin

0.001

• REVIEW: Oxytocin agonists for preventing PPH• COMPARISON: 01 Carbetocin versus oxytocin• OUTCOME: 02 Use of additional uterotonic therapy

0.1 1 10 100 1000Favours carbetocin Favours oxytocin

Su LL, et al. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005457

Conclusions

Prevention of PPHVaginal birth: active management, Oxytocin (3-5 IU), no prostaglandins, no ergometrinCaesarean section: Carbetocin (Pabal®), Oxytocin 5IU 2-3min – no bolus, no PGs, no ergometrin

Therapy of PPHOT (10-40 IU/liter), ergometrin (0.2mg every 2-3 hours)PGE2/PGF2alpha (0.25 mg i.m. every 15-90 min)Misoprostol 800-1000mcg rectally (off label)Carbetocin (off label)

HAEMOHAEMOSSTASISTASIS

S: transfer the patient to the operating room( exclude trauma or retained products, proceed with bimanual compression)

HAEMOSHAEMOSTTASISASIST: “Balloon Tamponade”;

HAEMOSHAEMOSTTASISASIST: “Balloon Tamponade”;

Uterine packing

(2009)

Traditional method

Bakri balloon Bakri balloon

TAMPONADE WITH BAKRI BALLOON

– Simple and efficient (87-95 % success rate)

– Applicable after cesarean and vaginal births

– Used as method of prevention in “cesareans at high hemorrhagic risk” (placental pathologies, uterine over-distension, preeclampsia, precedent hysterotomy, coagulopathy, etc) and in the case of contraindications for prostaglandins (asthma, glaucoma, important hepatic and renal dysfunction)

– Easy to insert and remove

– Continuous monitoring of blood loss

BAKRI BALLOON The Bakri is a balloon in silicon, latex-free, which is

filled with physiological solution (500 cc max) and is able to create a real intrinsic compression on the myometrial walls: the filling volume can be varied in relation to the dimension of the uterus and the contractile response

Additionally to the ease of insertion it has the possibility to monitor the amount of blood loss thanks to the drainage holes located in the distal part of the catheter, which is attached to a sac in order to collect the fluids. This access is used also to perform washings of the uterine cavity.

Associate adequate antibiotic coverage Removal of the balloon within 24 hrs administering

uterotonics/uterokinetics before deflating

Bakri balloon Bakri balloon

Bladder

Bakri balloon

Bakri balloon

The intrauterine balloon Ultrasound

myoma

BAKRI BALLOON

Catetere vescicale

HAEMOSTHAEMOSTAASISSISA: apply “sutures”

HAEMOSTHAEMOSTAASISSISA: apply “ compression sutures”

B-Lynch suture

Hayman uterine compressive sutures Does not necessitate to open

the uterine cavity

Cho multiple quadrate sutures

HAEMOSTHAEMOSTAASISSISA: apply “compressive sutures”

Suture of Hayman

HAEMOSTHAEMOSTAASISSISA: perform “ sutures”

HAEMOSTAHAEMOSTASSISISS: Systematic pelvic devascularization

Rescue Surgery: Ligation uterine artery and ovarian artery

Triple ligation of Tsiruinikov :

ligation of the uterine arteries, round ligament and the uterine-ovarian.

Vascular ligation

– Uterine

– Ovarian

– Int iliac

Vascular ligation

Ligation hypogastric artery

Underneath the superior gluteal artery

Rescue Surgery HAEMOSTAHAEMOSTASSISIS

Hansch E, etal. AJOG 1999

Hypogastric artery ligationsuccess 84%

(Limiting factors: hemodinamically stable cases - presence of angiographist - transport to radiology)

Fragments of gelfoam are injected (gelatin sponge resorbable in 10-30 days)

HAEMOSTASHAEMOSTASIISS

I: Interventional radiologist –”Uterine Artery Embolization”

HAEMOSTASHAEMOSTASIISSI: Interventional radiologist –”Uterine Artery Embolisation”

Rescue Surgery :

total hysterectomy / subtotal

1.55 % births

0.24% and 0.90% of all cesarean sections

between 1480 and 1800 hysterectomies/year associated with cesarean section

ISTAT 2006

HAEMOSTASIHAEMOSTASISSS : Subtotal or total abdominal hysterectomy

The ideal treatment should be:

intuitive and easy to apply

secure and effective in the “prevention” and the arrest of

hemorrhages

has an immediate result

avoids hysterectomy

Our Philosophy…

EFFICACY & EFFICIENCY

Team work

•TEAM- Obstetricians, Anesthetists, Blood bank, Interventional

Radiologists

Max therapeutic Max therapeutic efforts within 2-3 hrsefforts within 2-3 hrs

Contemporary Contemporary involvement of all involvement of all professional figuresprofessional figures

Liberal use of all Liberal use of all therapeutic agentstherapeutic agents

Follow in a stepwise way the guidelines

BASICS

1. INTERVENTIONAL RADIOLOGISTS IN THE THEATRE

2. CLAMPING UTERINE VESSELS BEFORE PLACENTAL DELIVERY

3. ASSOCIATION OF COMPRESSIVE SUTURES AND BAKRI BALLOON

INFORMED CONSENT

B-Lynch + Bakri Balloon

“ SANDWICH EFFECT“

B-Lynch + Bakri Balloon

IT LOOKS LIKE THE LUGGAGES OF IMMIGRANTS…..

NO RISK OF ISCHEMIA

Prevention of Postpartum Hemorrhage ( cases with elevated hemorrhagic risk: i.e., placenta previa post-C.S.)

STEP 1 PRELIMINARY PROPHYLACTIC

CATHETERIZATION OF THE DESCENDING AORTA

STEP 2 EXTRACTION OF THE FETUS BY C.S. AND PLACENTAL DELIVERY

STEP 3MULTIPLE QUADRATE ENDOUTERINE

HEMOSTATIC SUTURES

STEP 4PREPARATION OF B-LYNCH

COMPRESSIVE SUTURES

STEP 5 APPLICATION OF HYDROSTATIC BALLOON (BAKRI-BALLOON)

STEP 6

REPOSITIONING OF UTERUS –UTERINE SUTURES-HYDROSTATIC BALLOON

INFLATION-B-LYNCH LIGATURE

IF THESE MANEUVRES FAILDEVASCOLARIZATING LIGATURE /SELECTIVE EMBOLIZATION

/HYSTERECTOMY

STEP 1

Angiography

transomeral/transfemoral pre-carefour

STEP 2 DELIVERY OF THE FETUS

ADMINISTRATION OF CARBETOCIN

STEP 2 CLAMPING UTERINE VESSELS

Prevention of postpartum hemorrhage ( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )

Assistance Plan

STEP 2 Squared hemostatic endouterine sutures

Rationale: at the level of the inferior uterine segment reduced muscular component ; incomplete mechanical hemostasis after placental delivery; conspicuous hemorrhage

multiple quadrate sutures in the IUS of 2-3 cm, transdecidual. (Dexon n.1-2,needle with large curvature )

Retraction of the muscular fibers with clamping and occlusion of the vasculature Affro

nti

me

s

STEP 3 Squared hemostatic endouterine sutures

Prevention of postpartum hemorrhage ( cases at elevated hemorrhagic risk:ex. placenta previa in post-C.S. )

Assistance Plan

STEP 3 B-Lynch compressive sutures

The ligature of the sutures follows after STEP 4

STEP 4 PREPARATION OF B-LYNCH SUTURE

STEP 4

Prevention of postpartum hemorrhage

STEP 4 Application of hydrostatic balloon (Bakri balloon)

Uterine closure

Hydrostatic balloon inflation

B-Lynch suture ligature

STEP 5

BAKRI-BALLOON POSITIONING

MILD INFLATION OF THE BALLOON

STEP 5

REPOSITIONING THE UTERUS; FULL INFLATION OF BALLOON; B-LINCH SUTURE APPLIED

STEP 6

( Ex adiuvantibus ) postpartum hemorrhage

( Ex adiuvantibus )

Separatore cellulare a flusso continuo

Unità di gestione della temperatura corporea

postpartum hemorrhage

postpartum hemorrhage

ADULT INTENSIVE CARE UNIT POSTPARTUM

END POINT :

SURGICAL CONSERVATIVE TREATMENT

REACHED 95% ( 78 OUT OF 82 )

• 4 HYSTERECTOMIES

ONGOING

US SCANDIFFICULT CASES…….

RMNDIFFICULT CASES….

US SCAN CHECK AFTER 30 DAYS

DIFFICULT CASES ….

DIFFICULT CASES... ( 02.09.2011)

DIFFICULT CASES...... ( 02.09.2011)

DIFFICULT CASES... ( 02.09.2011)

DIFFICULT CASES...

CESAREAN HYSTERECTOMY

CESAREAN HYSTERECTOMY

CESAREAN HYSTERECTOMY

CESAREAN HYSTERECTOMY

ConsiderationsAll pregnancies are at risk of hemorrage in the post partum

even if at the moment of birth there were no risk factors.

Because our goal is to improve maternal health and prevent the possibility of death during the pregnancy or birth it is

fundamental to possess, other than a

solid preparation,

a trustworthy and well trained team and the necessary instruments.

( Bakri balloon;Cell sorter with continuous flow; FloSeal)

New conservative approach in the management of PPHG. Clerici, G. Epicoco, E. Bottaccioli, S. Arena, I. Giardina, G. C. Di Renzo, G. Affonti

University Hospital of Perugia, Perugia, Italy

INTRODUCTIONPostpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Most deaths occur within the first 4 hours after delivery, often as a consequence of placental delivery. Treatment option for PPH include conservative management (uteritonic drugs, selective devascularization by ligation or embolization of the uterine artery, external compression with uterine sutures and intrauterine packing). Failure of these options necessitates hysterectomy.The objective of the study is to report our experience with a conservative management protocol to treat PPH in high risk patients diagnosed with placenta previa/accreta.

METHODSA retrospective study of 49 patients (since October 2007) with placenta previa/accreta who underwent a conservative management protocol (see table).

RESULTSConservative management of PPH was successfully achieved in 48 patients (98%). In only one case it was necessary to perform post-partum hysterectomy for massive bleeding due to severe placental accretism. In another case it was necessary selective embolization of the right uterine artery due to the presence of hematoma in the right part of the lower uterine segment and in the right paracolpus. The mean estimated blood loss was 1620 ml (range 1100-2340 ml). The mean hospital stay was 5.5 days (range 4-10 days). 22 patients (45%) underwent intraoperative and postoperative blood transfusions and the mean transfused volume was 700 ml. 18 patients (37%) were admitted for 24-48 h to intensive care unit for intensive monitoring. 30% of patients experienced moderate fever in the first 24-48 h and they were treated with antibiotics.

CONCLUSIONSAll pregnancies are at risk of PPH. Its management is dictated by several considerations including hemodynamic status and desire to preserve fertility. Conservative interventions should represent mandatory step for treatment of PPH in high risk patients with placenta previa/accreta. The results of this conservative protocol are encouraging .

CONSERVATIVE MANAGEMENT PROTOCOL

STEP 1 –Preliminary prophylactic catheterization of the descending aorta

STEP 2 –Extraction of the fetus by C.S. and placental delivery

STEP 3 –Multiple quadrate endouterine haemostatic sutures

STEP 4-Preparation of B-Lynch compressive sutures

STEP 5 –Application of hydrostatic balloon (Bakri balloon)

STEP 6 –Repositioning of uterus - uterine sutures - hydrostatic balloon inflation – B-Lynch ligature

If the maneuvers fail the next step is devascolarizating ligature/selective

embolization of the uterine arteries.If all procedures fail, proceed with

hysterectomy.

• Monitoring of maternal hematologic parameters 24 hrs before C.S. and 2 h after the procedure, than every 2-4 h for the following 24 hrs in relation to clinical conditions.• Blood transfusion if the hemoglobin level decreases more than 7 g/dl and the hematocrit value is less than 21% ;• The Bakri balloon is removed 24 h after delivery.

Affronti

EMS

CONCLUSIONS

FACTS:FACTS:

All pregnancies are at risk of All pregnancies are at risk of

PPH even if no predisposing PPH even if no predisposing

factors are presentfactors are present

Luis G. Keith 2007

BOTTOM LINE

Averting maternal death is Averting maternal death is based on having a prepared based on having a prepared mind, a prepared team and mind, a prepared team and a full range of possible a full range of possible therapiestherapies

Luis G. Keith, 2007

Postpartum HemorrhageRecommendations:

•Every department needs to have a protocol for management of O.E., with periodic re-evaluation (Life Support training)•Cases at risk of E.O. need to give birth in a II-III level structure

•Uncontrollable hemorrhages may necessitate hysterectomy: an expert surgeon needs to be avaliable quickly 24 hrs a day

•Activate the multidisciplinary team early in the management of a case at risk

•Institutional guidelines for the treatment of hemorrhages with periodic simulation training (skills and drills)

THANK YOU