pph

1. Post Partum
Haemorrhage
Dr. Uma Gupta *Head & Prof. Obstetrics &
Gynecology
*M.D, MARD, FAIMER (CMCL 2012), PGDHHM,MHPE.
umankgupta@gmail.com
5/10/2021 Uma Gupta 1

2. Mumtaz Mahal
died
from postpartum
hemorrhage in
Burhanpur on 17
June 1631 while
giving birth to
her fourteenth
child, after a
prolonged labor
of approximately
30 hours.
5/10/2021 Uma Gupta 2

3. 5/10/2021 Uma Gupta 3
Learning Objectives
1. Define postpartum hemorrhage
2. Differentiate between primary and secondary postpartum
hemorrhage.
2.Describe prevention (active management of the third stage
of labour) and treatment of postpartum hemorrhage.
3. Recall the four Ts as causes of postpartum hemorrhage.
4. Identify risk factors for PPH.
5.Describe the implications of postpartum hemorrhage on
the health of the mother and baby.
6. Prevention and management of PPH

4. Postpartum hemorrhage (PPH) is leading
cause of maternal mortality, accounting for
one-third of all maternal deaths worldwide
PPH causes up to 60% of all maternal deaths
in developing countries.
The majority of these deaths - within 4
hours of delivery, indicating they are a
consequence of third stage of labour.
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5. • Primary (immediate) postpartum hemorrhage is
defined as excessive bleeding that occurs within the
first 24 hours after delivery.
• About 70% of immediate PPH cases are due to uterine
atony.
• Atony of the uterus is defined as the failure of the
uterus to contract adequately after the child is born.
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6. • Secondary (late) postpartum hemorrhage is
defined as excessive bleeding occurring between 24
hours after delivery of the baby and 6 weeks
postpartum. Most late PPH is due to retained
products of conception, or infection, or both
combined.
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7. Quantified
PPH has been defined as blood loss in excess of 500
cc in vaginal deliveries and in excess of 1,000 cc in
cesarean section deliveries. For clinical purposes,
any blood loss that has the potential to produce
hemodynamic compromise should be considered a
PPH.
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8. The amount of blood loss required to cause
hemodynamic compromise will depend on the pre-
existing condition of the woman.
Hemodynamic compromise is more likely to occur in
conditions such as anemia (e.g. iron deficiency, sickle
cell, and thalassemia) or volume contracted states
(e.g. dehydration, gestational hypertension with
proteinuria).
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9. 5/10/2021 Uma Gupta 9
Classification
• Primary : Loss within 1st 24 hours after delivery
• Secondary : 24 hours till 12 weeks postnatally
• Minor : 500-1000 ml
• Moderate : 1000-2000 ml
• Severe : > 2000 ml

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Clinical Findings With Varying
Amounts of Blood Loss
Blood loss will result in changes to the state of
consciousness, the pulse rate, the respiratory rate,
the temperature, the blood pressure, the status of
the skin and mucous membranes, capillary refilling,
and urine output.

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Estimating Blood Loss
• Accurate estimation of blood loss is essential in the
recognition and management of obstetric
hemorrhage. Underestimation of blood loss may
result in lack of recognition of PPH, and inadequate
or inappropriate management

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Direct Measurement
PAD 120 CC
TAMOPNE 50 CC
GUAZE 30 CC
SMALL ABDOMINAL PACK 250 CC
LARGE ABDOMINAL PACK 450 CC

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• Mild hypovolemia, loss of <20% of the blood
volume,
• mild tachycardia,
• mottled skin,
• cool extremities due to increased systemic vascular
resistance and prolonged capillary refilling,
• urinary output may be decreased.
• The woman may report dizziness, although her
neurologic status usually remains normal.

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• With moderate hypovolemia, i.e. loss of 20% to 40%
of the blood volume,
• woman will become increasingly anxious.
• pulse will become very fast and weak, >110/bpm
(tachycardia).
• Her respiratory rate will increase to a rate of
>30/bpm.
• will exhibit marked pallor; her eyelids, palms, and
mucous membranes will be very pale.
• Her blood pressure may be normal when she is in the
supine position. However, there may be significant
postural hypotension

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• When blood loss is severe, i.e. >40% of the blood
volume,
• the classic signs of shock will appear.
• The blood pressure declines and becomes unstable
even in the supine position.
• The woman will develop marked tachycardia,
oliguria or anuria, and agitation or confusion.
• Loss of consciousness is an ominous sign.

16. Rule of 30
This rule is used to measure severity of shock
resulting from at least 30% of blood loss –
• Increase in HR by >30 beats/min
• Fall in Systolic BP >30 mmHg
• RR >30/min
• Hematocrit drops by >30%
• Urine output <30ml/min
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17. 3.SHOCK INDEX (S.I)
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18. 5/10/2021 Uma Gupta 18
• Frequent measuring of birth fluids may help health
care providers become more skilled in assessing
blood loss. Health care providers should become
familiar with the absorbency of maternity pads,
under pads, and other surfaces on which maternal
blood may accumulate during delivery in their
practice location

19. REMEMBER
 Blood loss is consistently underestimated.
Underestimation may result in inadequate treatment
resulting in complications or death.
 Ongoing trickling can lead to significant blood loss.
Blood loss is generally well tolerated by healthy
women, to a point.
Anemia and other underlying health conditions may
profoundly affect a woman‘s ability to tolerate any
amount of blood loss.
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20. 5/10/2021 Uma Gupta 20
• Complications Associated With Postpartum
Hemorrhage
• Significant blood loss can occur very quickly. Women
can lose up to 500 ml of blood in 1 minute during a
PPH.
• The average woman has approximately 5 litres of
blood in her circulation. At this rate, it is possible for a
woman to become exsanguinated (lose all of her
blood) within 10 minutes. Rapid, efficient action must
be taken to save the woman‘s life and to prevent
complications related to significant blood loss

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Effects of PPH
• PPH is associated with orthostatic hypotension,
anemia, and fatigue.
• Postpartum anemia is associated with lactation failure
placing the health of the newly born infant at risk.
• It is also associated with postpartum depression that
may in turn affect maternal bonding with the
newborn. Maternal attachment to the newborn is
essential for the long-term well-being of the infant.
• Extreme fatigue resulting from anemia may make
maternal care of the newborn and other siblings more
difficult

22. Etiology
• Causes of PPH in terms of the Four T‘s:
• Tone - uterine atony
• Tissue - retained placenta or clots
• Trauma - uterine, cervical, or vaginal injury
• Thrombin - pre-existing or acquired coagulopathy
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CAUSES- THE ‘FOUR Ts’ OF PPH
CAUSE INCIDENCE (% )
TONE – atonic uterus 80
TRAUMA -
lacerations, rupture
10 – 15
TISSUE – retained
tissue
3 – 5
THROMBIN 1-2

24. Risk factors for postpartum hemorrhage
Etiologic Process (Cause) Clinical Risk Factors
Abnormalities
of Uterine
Contraction
(Tone)
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Over-distended uterus
•Polyhydramnios
• Multiple gestation
• Macrosomia
Uterine muscle exhaustion
• Rapid labour
• Prolonged labour
• High parity
Intraamniotic infection • Fever
• Prolonged rupture of membranes
(ROM)
Functional or anatomic
distortion of the uterus, i.e.
distended bladder may
prevent contraction of the
uterus
• Fibroid uterus
• Placenta previa or abruptio
• Uterine anomalies
Uterine-relaxing
medications
Uma Gu
• Halogenated anesthetics,
nitroglycerin, magnesium sulphate
pta 24

25. Living ligature
• Failure of this living ligature leads to atonicity of
uterus leading to PPH .
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Etiologic Process (Cause) Clinical Risk Factors
Retained Retained products • Incomplete placenta at
Products of abnormal placentation delivery
Conception retained cotyledon or • previous uterine surgery
(Tissue) succinturiate lobe • High parity
• Abnormal placenta on
ultrasound
• Retained blood clots •Atonic uterus

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Etiologic Process (Cause) Clinical Risk Factors
Genital Tract
Trauma
(Trauma)
• Tears (lacerations) of the cervix,
vagina, or perineum
• Ruptured vulval varicosities
• Precipitous delivery
• Operative delivery
• Mistimed or inappropriate
use of episiotomy
• Extensions, lacerations at cesarean
section • Malposition
• Deep engagement
Uterine rupture Previous uterine surgery
• Uterine inversion • High parity
• Fundal placenta

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Etiologic Process (Cause) Clinical Risk Factors
Abnormalities
of
Coagulation
(Thrombin)
• Pre-existing states
- hemophilia A
-von Willebrand‘s disease1
History of hereditary
coagulopathies
• History of liver disease
• Acquired in pregnancy
- idiopathic thrombocytopenic purpura2
- thrombocytopenia with preeclampsia
- disseminated intravascular coagulation
- preeclampsia
- dead fetus in utero
- severe infection/sepsis
- placental abruption
- amniotic fluid embolus
• bruising
• elevated BP
• elevated BP
• fetal demise
• fever
• elevated white blood
cells
• antepartum hemorrhage
• sudden collapse
Therapeutic anticoagulation history of thrombotic
disease

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Prevention
• Compared to expectant management, active
management of the third stage of labour (AMTSL) is
associated with
• ↓ maternal blood loss,
• ↓ postpartum hemorrhage,
• ↓ postpartum anemia,
• ↓ need for blood transfusions
• and a ↓ e in the incidence of prolonged third stage
of labour.

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What is active management of 3rd stage of labour?
Active management of 3rd stage of labour (AMTSL)
involves 3 steps after delivery of baby:
1. Uterotonic drug given immediately after birth of baby
2.Placenta delivered by controlled cord traction with
counter-traction on the fundus during contraction
3. Fundal massage after delivery of the placenta

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32. What are the oxytocic drugs used in AMTSL?
There are 4 kinds of drugs used in third stage of labor
• Oxytocin- posterior pituitary extract
• Ergometrine- preparation of ergot
• Syntometrine- combination of oxytocin and
ergometrine
• Misoprostol- prostaglandin E1 analogue
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33. Drugs Advantage Disadvantage
Oxytocin Causes uterus to contract
• Acts within 2.5 minutes when
given IM
• Generally does not cause side
effects
• Safe in hypertension
• IM or IV preparations only
• Not heat stable
Ergometrine
5/10/2021
Low price
• Effect lasts 2–4 hours
Uma Gupta
•Takes 6–7 minutes to
become effective when
given IM; oral form
insufficiently effective
• Causes tonic uterine
contraction
33

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Drugs Advantage Disadvantage
Syntometrine Combined effect of
rapid action of oxytocin
and sustained action of
ergometrine
Increased risk of
hypertension, nausea
and vomiting
• Not heat stable
Misoprostol
•Effective orally,
buccally, vaginally and
rectally
• Rapid absorption after
oral 3 minutes
T1/2 life = 20-40
minutes
•Predictable side
effects: shivering,
pyrexia, nausea,
vomiting and diarrhea
• Rate of PPH is higher
with misoprostol
compared to oxytocin.

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Management
of third stage
of labor
Blood Loss (>
1000 ml)
Physiologic 13-18%
Active
(oxytocin)
2.9%
Misoprostol 4%

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Management of PPH
Principles of management -
To replace the blood
To empty the uterus
To ensure effective hemostasis
For systematic management of PPH there is algorithm
known as
‘ HEMOSTASIS ’

37. HEMOSTASIS
H: Ask for help
A: Assess (vitals, blood loss) & resuscitate
E: Establish etiology & check Ecbolics
(syntometrine, ergometrine)Ensure availability
of blood
M: Massage uterus
O: Oxytocin infusion, prostaglandins
S: Shift to operating room, exclude retained
p
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d
1 ucts & trauma Uma Gupta 37

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CONT…
T: Tissue & Trauma to be excluded , proceed for
Tamponade , bakri balloon, uterine packing
A : Apply compression sutures
S : Systematic pelvic devascularization (uterine,
ovarian, internal iliac artery ligation)
I : Intervention radiologist, uterine artery
embolization
S : Subtotal or total abdominal hysterectomy

39. Assess
1. Assess Vital signs & Estimate Blood Loss
2. Adequate venous access : 2 large bore I/v
cannula(16-18G)
3. Draw Blood sample (~20ml) for haemogram,
Blood Group, Cross Match, Coagulation
screen, RFT & LFT
4. Foley’s catheter : Monitoring adequate renal
perfusion.
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40. Volume Replacement
5.Fluid of Choice – Crystalloid over colloids
6. Crystalloid of choice – Ringer Lactate
7. Loss of 1 Lit of blood requires replacement
with 4-5 Lit of crystalloids (NS or RL) or
colloids until cross matched blood Is available
(1 ml of blood loss= 3 ml of crystalloids)
8. The recommended transfusion ratio for
PRBC:FFP:RDP IS 1:1:1
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41. 5/10/2021 Uma Gupta 41
Medical management
1 . FIRST LINE DRUG
Oxytocin:
•Start with 10 units im and Infusion of 20 units in 1L
@ 60 drops /min.
•Continue same dose @ 40 drops/min until bleeding
stops.
• Maximum dose of 3 liters of oxytocin infusion

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SECOND LINE DRUG
Ergometrine/ methyl ergometrine:
• Dose: 0.2 mg im or slow iv Repeat 0.2mg after 15
min.
• Maximum 5 doses (1 mg) can be given
• Syntometrine im

43. Third line
Carboprost / (PGF2alpha)
Dose: 0.25mg (250µgm) mg im.
Can be repeated every 15 min.
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Maximum
upto 2 mg or8 doses can be given .
Misoprostol
• 200-800 µg sublingually. Do not exceed 800 µg

44. 3. Bimanual
Compression
•
•
•
•
Form a fist.
Place the fist in anterior
fornix & apply pressure
against the anterior wall of
uterus.
With the other hand press
deeply into the abdomen
behind the uterus to make it
anteverted.
Pressure against the posterior
wall of uterus Maintain
pressure until bleeding is
controlled & uterus contracts.
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45. 4. Shift to OT
• Patient is to be shifted to O.T
• By P/S examination rule out trauma to perineum ,
vagina, and cervix .
• If required then hemostasis sutures are to be taken by
catgut suture.
• Also examine the placenta for its completeness.
• Exploration of uterus is done .
• Evacuation of any product of conception if retained.
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46. 5. Uterine tamponade
1.Tight uterine packing
2. Balloon tamponade
a. Bakri balloon
b. Sengstaken Blakemore catheter
c. Condom catheter
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47. Intrauterine packing
• A long gauze of 5 metre soaked in antiseptic cream
is introduced inside the uterus and placed in to the
fundal area.
• Exerts direct haemostatic effect to open uterine
sinuses.
• Obselete now days because of risk of intra uterine
sepsis .
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48. Balloon tamponade
• Balloon Inflate balloon with 200- 500 ml warm 0.9 %
Sodium chloride.
• It adapts to shape of the uterine cavity and occludes
the venous sinus.
• If the bleeding is controlled it known as Positive
Tamponade Test.
• The catheter should not be removed within 12-
24hrs.
• Effectiveness – 88%
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51. 6.Compression sutures
1. B - Lynch suture
2. Hayman suture
3. Cho suture
 These suture causes bimanual compression of the
uterus.
 Apposes anterior and posterior wall of uterus.
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52. Cho and hayman suture
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53. B- Lynch suture
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7. Systematic pelvic devascularization
 Ligation of Uterine arteries
Ligation of Tubal branch of ovarian artery
 Ligation of Internal iliac artery
Ascending branch of uterine artery is ligated at
lateral border b/w upper and lower segment.
And ovarian artery is ligated just below ovarian
ligament.

55. Ligation of uterine and internal iliac
artery ( ascending branch)
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56. 8. Interventional radiology
• Angiographic selective arterial embolization
• Possible where facility of interventional radiology
available.
• Avoids hysterectomy
• Success rate of about 90 %
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57. 9. Hysterectomy
• If all procedures failed to control bleeding
Decision for hysterectomy is taken to
save mother life
• It may be subtotal or total hysterectomy.
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Transferring to referral centre
As PPH precedes Death by 2 hours”
If initial medical therapy fails within Golden Hour, then
shift the patient to higher centre.
Two important life savior methods -;
 Aortic compression by Skilled Birth Attendant
 Non Pneumatic Anti Shock Garment

59. 5/10/2021 Uma Gupta 59

60. •
NASG is a simple device -
Neoprene
•Shunts blood to vital organs
(anti-shock)
•It can shunt about 500- 1500
ml into central pool
NON–PNEUMATIC ANTI SHOCK GARMENT
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61. PREVENTION:
Prevention of PPH is not always possible but however its incidence can be reduced
By substantially assessing the risk factors and following guidelines as mentioned:
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•ANTENATAL:
1.Improvement of health status of women and to keep the haemoglobin level
normal(>10g/dl), so that the patient can withstand some amount of blood loss.
2.High risk patients who are likely to develop PPH (such as twins, hydramnios, grand
multipara, history of previous pph, severe anemia) are to be screened.
3.Blood grouping should be done for all womenso that no time is wasted during
emergency.

62. 4. Placental localization should for all women with previous cesarean delivery by USG or
MRI to detect placenta accreta or percreta or to determine morbid adherent placenta.
P.P
5. Women with morbid adherent placenta are at high risk of developing pph. Such a case
should be delivered by senior obstetrician. Availability of blood and blood products must
ensured before hand.
• INTRANATAL:
1. Active management of the third stage, for
reduces PPh by 60%
all women in labor should be a routine as it
2. Women delivered by cesarean section, oxytoxin 5 IU slow IV is to be given to reduce
blood loss. Carbetocin 100mcg is very useful to prevent PPH.
3. Exploration of the uterovaginal canal for evidence of trauma following difficult
labor or instrumental delivery.
4. Observation for about two hours after delivery to make sure that the uterus is hard and
well contracted before sending her to ward.
5. During cesarean section spontaneous separation and delivery of the placenta reduces
blood loss by 30%
6. Examination of the placenta and membranes should be a routine to detect at the
earliest any missing part.
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ASSESSMENT

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Question 1
• To be considered a PPH, what would the estimated
blood loss have to be for a C-section?
A. < 550 ML
B. > 600 ML
C. > 1000 ML
D. < 900 ML

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Question 1
• To be considered a PPH, what would the estimated
blood loss have to be for a C-section?
A. < 550 ML
B. > 600 ML
C. > 1000 ML
D. < 900 ML

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Question 2
• What types of trauma during labour and birth
would lead to PPH risk?
A. Instrumental assisted birth (vacuum or forceps)
B. C-Section
C. Lacerations of the cervix or vaginal wall
D. All of the above

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Question 2
• What types of trauma during labour and birth
would lead to PPH risk?
A. Instrumental assisted birth (vacuum or forceps)
B. C-Section
C. Lacerations of the cervix or vaginal wall
D. All of the above

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Question 3
• In which of these cases could you diagnose PPH
following vaginal delivery: 1. > 500 blood loss over
24 hrs 2. hypotension 3. tachycardia
A. 1 & 3
B. 2
C. 3
D. 1

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Question 3
• In which of these cases could you diagnose PPH
following vaginal delivery: 1. > 500 blood loss over
24 hrs 2. hypotension 3. tachycardia
A. 1 & 3
B. 2
C. 3
D. 1

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Question 4
• The 4 “T’s” of PPH are: 1. Trauma 2. Toxins 3.
Travel 4. Tissue 5. Threads 6. Thrombin 7.
Tears 8. Tone
A. 1, 4, 6 & 8
B. 1, 5 7 & 8
C. 1, 2, 3 & 6
D. 3, 4, 5 & 6

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Question 4
• The 4 “T’s” of PPH are: 1. Trauma 2. Toxins 3.
Travel 4. Tissue 5. Threads 6. Thrombin 7.
Tears 8. Tone
A. 1, 4, 6 & 8
B. 1, 5 7 & 8
C. 1, 2, 3 & 6
D. 3, 4, 5 & 6

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Question 5
• The normal blood flow through the placental site
each minute is 500-800 mls per minute.
A. True
B. False

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Question 5
• The normal blood flow through the placental site
each minute is 500-800 mls per minute.
A. True
B. False

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Question 6
• Which of these implantations would most likely
cause excessive bleeding?
A. Increta & Percreta
B. Normal & Accreta
C. Accreta & Increta
D. None of the above

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Question 6
• Which of these implantations would most likely
cause excessive bleeding?
A. Increta & Percreta
B. Normal & Accreta
C. Accreta & Increta
D. None of the above

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Question 7
• and are
the two most common causes of primary PPH.
(Tissue, Tone, Trauma, Thrombin)

77. Question 7
• Tone and _Trauma are the two
most common causes of primary PPH. (Tissue,
Tone, Trauma, Thrombin)
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Question 8
Ergometrine to control post-partum hemorrhage :
A.Is contraindicated in patient with high blood
pressure
B.It will not act on the smooth muscle of the blood
vessels
C. Intravenous root is the only way to be given
D. It can be used for induction of labor
E. Is safe in cardiac patient

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Question 8
Ergometrine to control post-partum hemorrhage :
A.Is contraindicated in patient with high blood
pressure
B.It will not act on the smooth muscle of the blood
vessels
C. Intravenous root is the only way to be given
D. It can be used for induction of labor
E. Is safe in cardiac patient

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Question 9
All of the following are used in treatment of PPH
except:
a.Misoprostol
b.Mifepristone
c.Carbaprost
d.Methyl ergometrine

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Question 9
All of the following are used in treatment of PPH
except:
a.Misoprostol
b.Mifepristone
c.Carbaprost
d.Methyl ergometrine

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Question 10
Carbetocin dose for PPH:
a.100 mcg IV
b.50 mcg IV
c.150 mcg IV
d.250 mcg IV

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Question 10
Carbetocin dose for PPH:
a.100 mcg IV
b.50 mcg IV
c.150 mcg IV
d.250 mcg IV

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Question 11
B Lynch suture is applied on:
a.Cervix
b.Uterus
c.Fallopian tube
d.Ovaries

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Question 11
B Lynch suture is applied on:
a.Cervix
b.Uterus
c.Fallopian tube
d.Ovaries

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Save the life of the one who
gives birth to a new life
THANK YOU

87. 5/10/2021 Uma Gupta 87
Reference
1. DC Dutta’s OBSTETRICS Including Perinatology and Contraception. 9th
Jaypee New Delhi
2. Tect Book of Obstetrics Sheila Balakrishnan. Paras Publishers, Delhi
Edition.
3. Self Assessment Review Obstetrics Sakshi Arora
4. Extracts from: http://www.commonhealth.in/pdf/8.pdf
5. World Health Organization. Managing complications in pregnancy and
childbirth: A
guide for midwives and doctors. . 2003.
5. Obstetrics by Ten Teachers. 20th Edition.CRC Press, Taylor and Francis group UK.
2017.

88. Twosome
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