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This document provides information about postpartum hemorrhage (PPH), including its definition, causes, risk factors, prevention, assessment, management, and treatment. Some key points: - PPH is a leading cause of maternal mortality worldwide, responsible for 1/3 of maternal deaths. The majority occur within 4 hours of delivery. - Causes (4 Ts) include uterine atony (80% of cases), retained placenta or clots, genital tract trauma, and coagulation disorders. - Risk factors include overdistended uterus, rapid/prolonged labor, uterine anomalies, and coagulation disorders. - Prevention is through active management of the third stage of labor

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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
5/10/2021 Uma Gupta 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.
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 5/10/2021 Uma Gupta 3
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. 5/10/2021 Uma Gupta 4
• 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. 5/10/2021 Uma Gupta 5
• 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. 5/10/2021 Uma Gupta 6
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. 5/10/2021 Uma Gupta 7
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). 5/10/2021 Uma Gupta 8
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 5/10/2021 Uma Gupta 9
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. 5/10/2021 Uma Gupta 10
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 5/10/2021 Uma Gupta 11
Direct Measurement PAD 120 CC TAMOPNE 50 CC GUAZE 30 CC SMALL ABDOMINAL PACK 250 CC LARGE ABDOMINAL PACK 450 CC 5/10/2021 Uma Gupta 12
• 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. 5/10/2021 Uma Gupta 13
• 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 5/10/2021 Uma Gupta 14
• 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. 5/10/2021 Uma Gupta 15
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 5/10/2021 Uma Gupta 16
3.SHOCK INDEX (S.I) 5/10/2021 Uma Gupta 17
• 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 5/10/2021 Uma Gupta 18
➢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. 5/10/2021 Uma Gupta 19
• 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 5/10/2021 Uma Gupta 20
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 5/10/2021 Uma Gupta 21
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 5/10/2021 Uma Gupta 22
CAUSES - THE ‘FOUR Ts’ OF PPH 5/10/2021 Uma Gupta 23 CAUSE INCIDENCE (% ) TONE – atonic uterus 80 TRAUMA - lacerations, rupture 10 – 15 TISSUE – retained tissue 3 – 5 THROMBIN 1-2
Risk factors for postpartum hemorrhage Etiologic Process (Cause) Clinical Risk Factors Abnormalities of Uterine Contraction (Tone) 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 • Halogenated anesthetics, nitroglycerin, magnesium sulphate 5/10/2021 Uma Gupta 24
Living ligature • Failure of this living ligature leads to atonicity of uterus leading to PPH . 5/10/2021 Uma Gupta 25
Etiologic Process (Cause) Clinical Risk Factors Retained Products of Conception (Tissue) Retained products abnormal placentation retained cotyledon or succinturiate lobe • Incomplete placenta at delivery • previous uterine surgery • High parity • Abnormal placenta on ultrasound • Retained blood clots •Atonic uterus 5/10/2021 Uma Gupta 26
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 5/10/2021 Uma Gupta 27
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 5/10/2021 Uma Gupta 28
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. 5/10/2021 Uma Gupta 29
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 5/10/2021 Uma Gupta 30
5/10/2021 Uma Gupta 31
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 5/10/2021 Uma Gupta 32
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 Low price • Effect lasts 2–4 hours • Takes 6–7 minutes to become effective when given IM; oral form insufficiently effective • Causes tonic uterine contraction 5/10/2021 Uma Gupta 33
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. 5/10/2021 Uma Gupta 34
Management of third stage of labor Blood Loss (> 1000 ml) Physiologic 13-18% Active (oxytocin) 2.9% Misoprostol 4% 5/10/2021 Uma Gupta 35
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 ’ 5/10/2021 Uma Gupta 36
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 products & trauma 5/10/2021 Uma Gupta 37
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 5/10/2021 Uma Gupta 38
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. 5/10/2021 Uma Gupta 39
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 5/10/2021 Uma Gupta 40
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 5/10/2021 Uma Gupta 41
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 5/10/2021 Uma Gupta 42
Third line Carboprost / (PGF2alpha) Dose: 0.25mg (250µgm) mg im. Can be repeated every 15 min. Maximum upto 2 mg or8 doses can be given . Misoprostol • 200-800 µg sublingually. Do not exceed 800 µg 5/10/2021 Uma Gupta 43
3. Bimanual Compression 5/10/2021 Uma Gupta 44 • • • • 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.
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. 5/10/2021 Uma Gupta 45
5. Uterine tamponade 1.Tight uterine packing 2. Balloon tamponade a. Bakri balloon b. Sengstaken Blakemore catheter c. Condom catheter 5/10/2021 Uma Gupta 46
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 . 5/10/2021 Uma Gupta 47
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% 5/10/2021 Uma Gupta 48
5/10/2021 Uma Gupta 49
5/10/2021 Uma Gupta 50
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. 5/10/2021 Uma Gupta 51
Cho and hayman suture 5/10/2021 Uma Gupta 52
5/10/2021 Uma Gupta 53 B- Lynch suture
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. 5/10/2021 Uma Gupta 54
Ligation of uterine and internal iliac artery ( ascending branch) 5/10/2021 Uma Gupta 55
8. Interventional radiology • Angiographic selective arterial embolization • Possible where facility of interventional radiology available. • Avoids hysterectomy • Success rate of about 90 % 5/10/2021 Uma Gupta 56
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. 5/10/2021 Uma Gupta 57
Transferring to referral centre 5/10/2021 Uma Gupta 58 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
5/10/2021 Uma Gupta 59
• 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 5/10/2021 Uma Gupta 60
PREVENTION: 5/10/2021 Uma Gupta 61 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: •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.
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 all women in labor should be a routine as it reduces PPh by 60% 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. 5/10/2021 Uma Gupta 62
ASSESSMENT 5/10/2021 Uma Gupta 63
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 5/10/2021 Uma Gupta 64
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 5/10/2021 Uma Gupta 65
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 5/10/2021 Uma Gupta 66
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 5/10/2021 Uma Gupta 67
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 5/10/2021 Uma Gupta 68
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 5/10/2021 Uma Gupta 69
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 5/10/2021 Uma Gupta 70
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 5/10/2021 Uma Gupta 71
Question 5 • The normal blood flow through the placental site each minute is 500-800 mls per minute. A. True B. False 5/10/2021 Uma Gupta 72
Question 5 • The normal blood flow through the placental site each minute is 500-800 mls per minute. A. True B. False 5/10/2021 Uma Gupta 73
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 5/10/2021 Uma Gupta 74
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 5/10/2021 Uma Gupta 75
Question 7 • _________________ and ________________ are the two most common causes of primary PPH. (Tissue, Tone, Trauma, Thrombin) 5/10/2021 Uma Gupta 76
Question 7 • _____Tone__ and _Trauma__________ are the two most common causes of primary PPH. (Tissue, Tone, Trauma, Thrombin) 5/10/2021 Uma Gupta 77
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 5/10/2021 Uma Gupta 78
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 5/10/2021 Uma Gupta 79
Question 9 All of the following are used in treatment of PPH except: a.Misoprostol b.Mifepristone c.Carbaprost d.Methyl ergometrine 5/10/2021 Uma Gupta 80
Question 9 All of the following are used in treatment of PPH except: a.Misoprostol b.Mifepristone c.Carbaprost d.Methyl ergometrine 5/10/2021 Uma Gupta 81
Question 10 Carbetocin dose for PPH: a.100 mcg IV b.50 mcg IV c.150 mcg IV d.250 mcg IV 5/10/2021 Uma Gupta 82
Question 10 Carbetocin dose for PPH: a.100 mcg IV b.50 mcg IV c.150 mcg IV d.250 mcg IV 5/10/2021 Uma Gupta 83
Question 11 B Lynch suture is applied on: a.Cervix b.Uterus c.Fallopian tube d.Ovaries 5/10/2021 Uma Gupta 84
Question 11 B Lynch suture is applied on: a.Cervix b.Uterus c.Fallopian tube d.Ovaries 5/10/2021 Uma Gupta 85
Save the life of the one who gives birth to a new life THANK YOU 5/10/2021 Uma Gupta 86
Reference 1. DC Dutta’s OBSTETRICS Including Perinatology and Contraception. 9th Edition. Jaypee New Delhi 2. Tect Book of Obstetrics Sheila Balakrishnan. Paras Publishers, Delhi 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. 5/10/2021 Uma Gupta 87
Twosome 5/10/2021 Uma Gupta 88

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Pph

  • 1.
    Post Partum Haemorrhage Dr. UmaGupta *Head & Prof. Obstetrics & Gynecology *M.D, MARD, FAIMER (CMCL 2012), PGDHHM,MHPE. umankgupta@gmail.com 5/10/2021 Uma Gupta 1
  • 2.
    5/10/2021 Uma Gupta2 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.
  • 3.
    Learning Objectives 1. Definepostpartum 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 5/10/2021 Uma Gupta 3
  • 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. 5/10/2021 Uma Gupta 4
  • 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. 5/10/2021 Uma Gupta 5
  • 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. 5/10/2021 Uma Gupta 6
  • 7.
    Quantified PPH has beendefined 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. 5/10/2021 Uma Gupta 7
  • 8.
    The amount ofblood 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). 5/10/2021 Uma Gupta 8
  • 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 5/10/2021 Uma Gupta 9
  • 10.
    Clinical Findings WithVarying 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. 5/10/2021 Uma Gupta 10
  • 11.
    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 5/10/2021 Uma Gupta 11
  • 12.
    Direct Measurement PAD 120CC TAMOPNE 50 CC GUAZE 30 CC SMALL ABDOMINAL PACK 250 CC LARGE ABDOMINAL PACK 450 CC 5/10/2021 Uma Gupta 12
  • 13.
    • 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. 5/10/2021 Uma Gupta 13
  • 14.
    • With moderatehypovolemia, 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 5/10/2021 Uma Gupta 14
  • 15.
    • When bloodloss 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. 5/10/2021 Uma Gupta 15
  • 16.
    Rule of 30 Thisrule 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 5/10/2021 Uma Gupta 16
  • 17.
  • 18.
    • Frequent measuringof 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 5/10/2021 Uma Gupta 18
  • 19.
    ➢REMEMBER ➢ Blood lossis 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. 5/10/2021 Uma Gupta 19
  • 20.
    • Complications AssociatedWith 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 5/10/2021 Uma Gupta 20
  • 21.
    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 5/10/2021 Uma Gupta 21
  • 22.
    Etiology • Causes ofPPH 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 5/10/2021 Uma Gupta 22
  • 23.
    CAUSES - THE‘FOUR Ts’ OF PPH 5/10/2021 Uma Gupta 23 CAUSE INCIDENCE (% ) TONE – atonic uterus 80 TRAUMA - lacerations, rupture 10 – 15 TISSUE – retained tissue 3 – 5 THROMBIN 1-2
  • 24.
    Risk factors forpostpartum hemorrhage Etiologic Process (Cause) Clinical Risk Factors Abnormalities of Uterine Contraction (Tone) 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 • Halogenated anesthetics, nitroglycerin, magnesium sulphate 5/10/2021 Uma Gupta 24
  • 25.
    Living ligature • Failureof this living ligature leads to atonicity of uterus leading to PPH . 5/10/2021 Uma Gupta 25
  • 26.
    Etiologic Process (Cause)Clinical Risk Factors Retained Products of Conception (Tissue) Retained products abnormal placentation retained cotyledon or succinturiate lobe • Incomplete placenta at delivery • previous uterine surgery • High parity • Abnormal placenta on ultrasound • Retained blood clots •Atonic uterus 5/10/2021 Uma Gupta 26
  • 27.
    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 5/10/2021 Uma Gupta 27
  • 28.
    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 5/10/2021 Uma Gupta 28
  • 29.
    Prevention • Compared toexpectant 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. 5/10/2021 Uma Gupta 29
  • 30.
    What is activemanagement 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 5/10/2021 Uma Gupta 30
  • 31.
  • 32.
    What are theoxytocic 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 5/10/2021 Uma Gupta 32
  • 33.
    Drugs Advantage Disadvantage OxytocinCauses 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 Low price • Effect lasts 2–4 hours • Takes 6–7 minutes to become effective when given IM; oral form insufficiently effective • Causes tonic uterine contraction 5/10/2021 Uma Gupta 33
  • 34.
    Drugs Advantage Disadvantage SyntometrineCombined 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. 5/10/2021 Uma Gupta 34
  • 35.
    Management of third stage oflabor Blood Loss (> 1000 ml) Physiologic 13-18% Active (oxytocin) 2.9% Misoprostol 4% 5/10/2021 Uma Gupta 35
  • 36.
    Management of PPH Principlesof management - To replace the blood To empty the uterus To ensure effective hemostasis For systematic management of PPH there is algorithm known as ‘ HEMOSTASIS ’ 5/10/2021 Uma Gupta 36
  • 37.
    HEMOSTASIS H: Ask forhelp 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 products & trauma 5/10/2021 Uma Gupta 37
  • 38.
    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 5/10/2021 Uma Gupta 38
  • 39.
    Assess 1. Assess Vitalsigns & 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. 5/10/2021 Uma Gupta 39
  • 40.
    Volume Replacement 5. Fluidof 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 5/10/2021 Uma Gupta 40
  • 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 5/10/2021 Uma Gupta 41
  • 42.
    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 5/10/2021 Uma Gupta 42
  • 43.
    Third line Carboprost /(PGF2alpha) Dose: 0.25mg (250µgm) mg im. Can be repeated every 15 min. Maximum upto 2 mg or8 doses can be given . Misoprostol • 200-800 µg sublingually. Do not exceed 800 µg 5/10/2021 Uma Gupta 43
  • 44.
    3. Bimanual Compression 5/10/2021 UmaGupta 44 • • • • 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.
  • 45.
    4. Shift toOT • 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. 5/10/2021 Uma Gupta 45
  • 46.
    5. Uterine tamponade 1.Tightuterine packing 2. Balloon tamponade a. Bakri balloon b. Sengstaken Blakemore catheter c. Condom catheter 5/10/2021 Uma Gupta 46
  • 47.
    Intrauterine packing • Along 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 . 5/10/2021 Uma Gupta 47
  • 48.
    Balloon tamponade • BalloonInflate 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% 5/10/2021 Uma Gupta 48
  • 49.
  • 50.
  • 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. 5/10/2021 Uma Gupta 51
  • 52.
    Cho and haymansuture 5/10/2021 Uma Gupta 52
  • 53.
    5/10/2021 Uma Gupta53 B- Lynch suture
  • 54.
    7. Systematic pelvicdevascularization ▪ 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. 5/10/2021 Uma Gupta 54
  • 55.
    Ligation of uterineand internal iliac artery ( ascending branch) 5/10/2021 Uma Gupta 55
  • 56.
    8. Interventional radiology •Angiographic selective arterial embolization • Possible where facility of interventional radiology available. • Avoids hysterectomy • Success rate of about 90 % 5/10/2021 Uma Gupta 56
  • 57.
    9. Hysterectomy • Ifall procedures failed to control bleeding Decision for hysterectomy is taken to save mother life • It may be subtotal or total hysterectomy. 5/10/2021 Uma Gupta 57
  • 58.
    Transferring to referralcentre 5/10/2021 Uma Gupta 58 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.
  • 60.
    • NASG is asimple device - Neoprene •Shunts blood to vital organs (anti-shock) •It can shunt about 500- 1500 ml into central pool NON–PNEUMATIC ANTI SHOCK GARMENT 5/10/2021 Uma Gupta 60
  • 61.
    PREVENTION: 5/10/2021 Uma Gupta61 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: •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 localizationshould 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 all women in labor should be a routine as it reduces PPh by 60% 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. 5/10/2021 Uma Gupta 62
  • 63.
  • 64.
    Question 1 • Tobe 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 5/10/2021 Uma Gupta 64
  • 65.
    Question 1 • Tobe 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 5/10/2021 Uma Gupta 65
  • 66.
    Question 2 • Whattypes 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 5/10/2021 Uma Gupta 66
  • 67.
    Question 2 • Whattypes 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 5/10/2021 Uma Gupta 67
  • 68.
    Question 3 • Inwhich 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 5/10/2021 Uma Gupta 68
  • 69.
    Question 3 • Inwhich 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 5/10/2021 Uma Gupta 69
  • 70.
    Question 4 • The4 “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 5/10/2021 Uma Gupta 70
  • 71.
    Question 4 • The4 “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 5/10/2021 Uma Gupta 71
  • 72.
    Question 5 • Thenormal blood flow through the placental site each minute is 500-800 mls per minute. A. True B. False 5/10/2021 Uma Gupta 72
  • 73.
    Question 5 • Thenormal blood flow through the placental site each minute is 500-800 mls per minute. A. True B. False 5/10/2021 Uma Gupta 73
  • 74.
    Question 6 • Whichof these implantations would most likely cause excessive bleeding? A. Increta & Percreta B. Normal & Accreta C. Accreta & Increta D. None of the above 5/10/2021 Uma Gupta 74
  • 75.
    Question 6 • Whichof these implantations would most likely cause excessive bleeding? A. Increta & Percreta B. Normal & Accreta C. Accreta & Increta D. None of the above 5/10/2021 Uma Gupta 75
  • 76.
    Question 7 • _________________and ________________ are the two most common causes of primary PPH. (Tissue, Tone, Trauma, Thrombin) 5/10/2021 Uma Gupta 76
  • 77.
    Question 7 • _____Tone__and _Trauma__________ are the two most common causes of primary PPH. (Tissue, Tone, Trauma, Thrombin) 5/10/2021 Uma Gupta 77
  • 78.
    Question 8 Ergometrine tocontrol 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 5/10/2021 Uma Gupta 78
  • 79.
    Question 8 Ergometrine tocontrol 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 5/10/2021 Uma Gupta 79
  • 80.
    Question 9 All ofthe following are used in treatment of PPH except: a.Misoprostol b.Mifepristone c.Carbaprost d.Methyl ergometrine 5/10/2021 Uma Gupta 80
  • 81.
    Question 9 All ofthe following are used in treatment of PPH except: a.Misoprostol b.Mifepristone c.Carbaprost d.Methyl ergometrine 5/10/2021 Uma Gupta 81
  • 82.
    Question 10 Carbetocin dosefor PPH: a.100 mcg IV b.50 mcg IV c.150 mcg IV d.250 mcg IV 5/10/2021 Uma Gupta 82
  • 83.
    Question 10 Carbetocin dosefor PPH: a.100 mcg IV b.50 mcg IV c.150 mcg IV d.250 mcg IV 5/10/2021 Uma Gupta 83
  • 84.
    Question 11 B Lynchsuture is applied on: a.Cervix b.Uterus c.Fallopian tube d.Ovaries 5/10/2021 Uma Gupta 84
  • 85.
    Question 11 B Lynchsuture is applied on: a.Cervix b.Uterus c.Fallopian tube d.Ovaries 5/10/2021 Uma Gupta 85
  • 86.
    Save the lifeof the one who gives birth to a new life THANK YOU 5/10/2021 Uma Gupta 86
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    Reference 1. DC Dutta’sOBSTETRICS Including Perinatology and Contraception. 9th Edition. Jaypee New Delhi 2. Tect Book of Obstetrics Sheila Balakrishnan. Paras Publishers, Delhi 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. 5/10/2021 Uma Gupta 87
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