Postpartum hemorrhage (PPH)  is a condition where a woman has heavy bleeding within 24 hours after giving birth. It’s normal to lose some blood after giving birth. However, in case of vaginal delivery if the woman loses more than 500 ml of blood, or if she loses more than 1000 ml of blood in a C-section delivery, then it is regarded as PPH. It can cause a severe drop in blood pressure, palpitations, dizziness, nausea and, swelling or pain around the vagina or perineum.

At this stage, there can be a limited supply of oxygen to the brain, heart and lungs because blood accumulates in the lower abdomen and legs. This state of shock can be reversed by applying an anti-shock garment called NASG or Non-Pneumatic Anti Shock Garment on the patient. NASG applies circumferential counter pressure, which curbs internal bleeding and stabilizes the patient’s blood pressure until she receives further medical attention.

This article primarily aims at management of PPH within a hospital setting.

Once PPH is identified, consider the following prerequisites before moving the patient to an appropriate care unit

  1. Informed consent
  2. Application of NASG (discussed in the following section)
  3. Availability of a bed/doctor in the referral hospital
  4. Indwelling Catheter with Urosac
  5. Vaginal pack in traumatic PPH
  6. Tamponade in atonic PPH
  7. Record presence of Pack/Tamponade – Do not remove until the patient reaches the destination
  8. Referral documents
    1. Antenatal Record with risk factors
    2. Intranatal events:
      • Delivery notes: Vaginal/Instrumental/ Caesarean section
      • Time of delivery of Baby/PlacentaEpisiotomy/Vaginal laceration/Cervical tear
  9. Investigation results
  10. Sequence of events
  11. Medication administered with time & dose
  12. Fluids administered
  13. Condition on Transfer

Equipping the patient with NASG

NASG is a portable and lightweight (1500 g) compression suit made of Neoprene. It applies pressure on the legs and abdomen and has six segments enclosing the ankle, calves, thighs, pelvis and abdomen. There is a small foam ball in the abdominal segment which applies pressure on the uterus. NASG controls bleeding through direct pressure and enables auto transfusion of blood in an upward direction.

How to apply NASG

A correct application of NASG supplies 20 to 40 mm Hg of circumferential pressure to the lower body, thereby effectively reversing hypovolemic shock. It has Velcro fastenings to secure the garment in place. The application takes less than 60 seconds when used by a trained resource.

Markings on the sections show how to apply

nasg-management-of-pph-sheela-mane

Step 1:

  • Place NASG under the woman with the top at the level of the lowest rib
  • Fasten Segment 1 tightly around the ankle on both sides

Step 2:

  • Fasten Segment 2 around the calf muscle
  • Leave the knee joint free

Step 3:

  • Fasten Segment 3 around the thighs

Step 4:

  • Fasten Segment 4 around the patient with the lower edge of the segment at the level of the pubic bone

Step 5:

  • Fasten Segment 5 with pressure ball directly over the umbilicus
  • Secure the NASG using Segment 6
  • Only one person should fasten Segment 4 & 5
  • The NASG should not be too tight to restrict breathing

Step 6:

  • Ensure the patient is breathing normally after the application
  • In case of uterine atony, administer uterotonics & massage the uterus without removing the NASG

The next step is to transfer the patient to the appropriate care unit as outlined below:

  1. From PHC to First Referral unit, in case of
    • Traumatic PPH or
    • Retained placenta or
    • Class I hemorrhage
  1. From Labor room to OT, in case of
    • Traumatic PPH or
    • Retained placenta or
    • Class II hemorrhage
  1. From Nursing home with OT to Hospital with HDU & ICU, in case of
    • Uncontrolled Class II

While moving the patient, a nurse/ doctor along with an able attendant must accompany the patient. It is also essential to provide the patient with the following during the transfer:

  1. Nasal Oxygen
  2. Two IV lines (#16/18) with fluid

Procedure/ Surgery to follow post patient transfer:

  1. Vaginal Procedures with NASG in situ
    • Pelvic examination
    • Lithotomy position
    • Repair of episiotomy/ Perineal tear/ Vaginal laceration/ Cervical tear
    • MRP
    • Bimanual compression
    • D&C/ D&E/ MVA
  2. Surgery with NASG in situ
    • Laparotomy (Keep segments 1,2&3 in situ and open pelvic & abdominal segments 4,5&6 just prior to incision)
    • Steep Trendelenberg position
    • Operate quickly
    • Fasten segment 4, 5 & 6 after the procedure

When to remove NASG?

For removal of NASG, the patient’s state must be in sync with the below conditions:

  1. The patient is stable for 2 hours
  2. Bleeding is less than 50 ml/hour
  3. Pulse is less than 100 BPM
  4. Systolic BP is between 90-100 mm Hg
  5. Hemoglobin is more than 7g/dL
  6. The patient is conscious and aware

How to remove NASG?

Step 1: Remove segment 1 and wait for 15 minutes

Step 2: Check pulse & BP

Step 3: If the pulse rate increases by 20 BPM or BP falls by 20 mm Hg, then reapply Segment 1

Step 4: If vitals are stable, remove Segment 2

Step 5: Repeat the same steps until the removal of Segment 6

Precautions to be taken:

  1. Wait for all vital signs to restore, then remove NASG
  2. Consider the need for crystalloids/ blood
  3. In case of recurrent bleeding, determine the source and arrest

How to store NASG?

  1. Clean NASG with plain water. Disinfect it and dry
  2. Keep NASG in a clear plastic bag
  3. Store NASG in a place where it is visible & accessible
  4. Ensure everyone knows the storage area
  5. The referral center must send a replacement NASG after receiving the patient

Advantages of NASG

  1. 50-78% reduction in blood loss
  2. 50-55% reduction in Maternal Mortality & related Morbidity
  3. WHO includes NASG in recommendations
  4. Cost effective
  5. Reusable

Relative contraindications – NASG application should be carried out with caution in case of:

  1. Cardiac failure
  2. Pre-existing Mitral stenosis/ Pulmonary edema
  3. Abdominal evisceration
  4. Open pelvic fracture

The NASG is designed to decrease further bleeding for women with obstetric hemorrhage.Hence, if a patient receives NASG at the right time, she will be in a better state to survive delays in reaching the appropriate care unit. It would also help her recover more quickly from shock, at a cost that is highly acceptable.

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