The document, authored by Dr. Niranjan Chavan, discusses the significance of obstetric hemorrhage as a major cause of maternal morbidity and mortality, highlighting the need for organizational preparedness, risk factor identification, and innovative management strategies. It presents an overview of the definitions of postpartum hemorrhage (PPH), its causes, and clinical strategies for its prevention and management. Additionally, it emphasizes the importance of team training, resource allocation, and supporting patients and families in the context of obstetric hemorrhage care.

1. RRRR IN OBSTETRIC
HEMORRHAGE

2. Name : Dr. Niranjan Chavan
MBBS,MD,FCPS,DGO,MICOG, DICOG,
FICOG,DFP,DIPLOMA IN ENDOSCOPY(USA).
Affiliation :Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H,
Sion Hospital
President, MOGS (2022-2023),
Joint Treasurer, FOGSI (2021-2025),
Organising Secretary, AICOG, Mumbai 2025,
Treasurer, AFG (2023-2024)
Title : RRRR IN OBSTETRIC HEMORRHAGE
City : Mumbai
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eagle’s eye, a lion’s heart, and
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Surgery must be done with 3S
& 1R
Swift
Safe
Sure
Relentlessly

4. Obstetric hemorrhage and its associated complications remain an important
cause of maternal morbidity and mortality and are often preventable.
Changing definitions, expanding the range of causes, different interventions
and guidelines, and lack of innovation are some of the issues that continue to
make meaningful risk reduction difficult.
The ways to help reduce risk include helping to secure the necessary
resources, establishing team training and simulation programs, developing
interventions to minimize cognitive bias, and using patient stories.
INTRODUCTION

5. .
Without a doubt, the need for organizational preparedness, including
access to medical care, appropriate training, and availability of blood
banks, remains essential.
However, even in well-equipped facilities, obstetric hemorrhage remains
a quality problem that varies in definition and management.

6. Causes of maternal mortality

7. BACKGROUND:
The definition of PPH is based on the amount of
blood loss after birth.
According to the WHO, PPH is defined as a blood
loss of more than 500 mL from the genital tract
after vaginal delivery.
However, 500 mL is selected as a cut-off, which is
also considered normal postpartum blood loss.
For vaginal births, severe PPH is defined as loss
of >1000 ml. In cases of cesarean birth, PPH is
defined as blood loss more than 1000 ml.

8. According to the American College of Obstetricians and Gynecologists
(ACOG), the definition of PPH is cumulative blood loss more than or equal
to 1000 ml that is associated with signs or symptoms reflecting
hypovolemia within the first 24 hours of the birthing process.
Low systolic blood pressure, tachycardia, and a raised respiratory rate
have been historically used as signs of hypovolemia.

11. Risk factors for Postpartum Hemorrhage:
Pregnancy itself is a risk factor for PPH, every pregnancy can result in PPH.
The risk factors for postpartum hemorrhage are classified according to
Maternal
Fetal
Placental.
Risk factors are also classified as
Intrapartum
Postpartum

15. Physiology of Uterine Contractions:
Parturition involves two main steps:
1. A long conditioning phase
2. A short secondary phase (active labor)
The conditioning step leads to the softening of the cervix. In the myometrium,
the preparatory process involves changes in transduction mechanisms and
synthesis of several proteins including connexins, ion channels, and receptors
for uterotonics, the downregulation of nitric oxide[NO] leads to the withdrawal
of uterine relaxation.(3)

16. Uterine Atony:
Primary PPH due to uterine atony occurs when the relaxed
myometrium fails to constrict the blood vessels, causing
hemorrhage.
Uterine atony is responsible for 75%-90% of primary PPH,
and 20% of all primary PPH is due to traumatic causes
(including obstetric lacerations, uterine inversion, and
uterine rupture).
" Atonic PPH is a recognized complication and, even if a
cesarean section is performed, severe intraoperative bleeding
is a significant risk.

17. Etiology:
Causes of primary postpartum hemorrhage -Mnemonic 4Ts …that stands for Tone,
Trauma, Tissue, and Thrombus.
 Tone:
Stands for the lack of tone or atony i.e. uterine atony, which is by far the most
common cause of postpartum hemorrhage. It accounts for the majority of PPH cases
and is the leading cause of hemorrhage-related mortality, followed by uterine
rupture, abruptio placenta, and placenta accreta spectrum.

18.  Trauma:
Refers to lacerations along the birth canal sustained during the birth process, most
commonly in the perineum and vagina and less often in the cervix, or laceration of
blood vessels (e.g. uterine artery) during cesarean section

19. FORNICEAL TEAR FOURTH-DEGREE PERINEAL TEAR

20.  Tissue:
Refers to retained placental tissue or
membranes, and it requires identification
through ultrasound or manual examination,
and evacuation of that tissue often
surgically via curettage of the uterus.

21. RETAINED PRODUCTS OF
CONCEPTION

22.  Thrombus:
Refers to the diminished ability of the
blood to clot properly due to different
constitutional deficits (e.g. hemophilia) or
acquired disease (e.g. consumptive
coagulopathy).

24. Clinical Strategies (Individual)
The bundle on Obstetric hemorrhage includes key elements within four domains
readiness, recognition and prevention, response, reporting and systems.
 Readiness:
Structural preparation elements such as blood collection carts and
comprehensive transfusion protocols are one-time investments in safety and
should not result in undue delays. Investing in team training is critical to using
shared mental models to promote optimal and standardized responses.

25.  Recognition and Prevention:
Early recognition is very important as
prevention is better than cure. It should be
done by prompt observation of uterine
tone, vitals and amount of blood loss.

26.  Response: Standardized step-based responses remain difficult, and
multidisciplinary efforts aimed at adapting existing resources and templates
to specific unit (and facility) environments, resources, and team member
clinical capabilities, efforts are needed.

27.  Reporting and Systems: The
learning objective is to identify
the root causes of morbidity or
mortality associated with
obstetric hemorrhage.
Multidisciplinary quality and
patient safety teams can help in
this field.

28. MANAGEMENT OF PPH

31. Clinical Strategies (Global)
 Standardization of Current Practices:
There is a need for more standardization of obstetric hemorrhage risk
assessment and management.
The efficacy of a standardized approach was demonstrated in obstetric
hemorrhage: Shields et al showed that the implementation of a
comprehensive protocol for maternal hemorrhage led to earlier
intervention, less transfusion, and quicker resolution of coagulopathy.

32.  Innovation in Treatment:
Most recently tranexamic acid, though known and used in the trauma arena, has been
shown to reduce mortality and return to the operating room in a large global study
(WOMAN trial).
Similarly, few tools or instruments are available to address advanced cases of
hemorrhage, such as balloon- or vacuum-induced tamponade.
Finally, the management of the placenta accreta spectrum remains focused on
hysterectomy as a definitive treatment while other treatments, such as conservative
treatment, remain experimental.
Areas that can be served by further innovation include further investigation of
hemostasis in pregnancy and potential applications for new tests (as currently seen
with viscoelastography), devices, or medications, and the exploration of artificial
intelligence to enhance the prediction of obstetric hemorrhage and anticipatory
interventions for prevention.

33. Non-Clinical Strategies:
 Dissemination:
The effectiveness of dissemination of clinical practice guidelines, protocols,
and policies in improving practices has been found wanting
 Audit and feedback: The dependence of effectiveness on human factors
highlights the need to explore other methods, such as team training, choice
architecture, and use of adjuncts such as the judicious use of alerts, and
checklists.

34.  Resources:
Human and physical resources remain a major issue for
the fight against hemorrhage-related morbidity and
mortality.
Physical resources should not be an issue: all providers
should have the medications necessary within their
armamentarium and that every primary response team
has a contingency team in case a case becomes
medically (e.g. a transfusion expert) or surgically (a
gynecologic oncologist) complicated.

35.  Competencies Teaming Training and Simulation:
Building the competencies of the team members can be reinforced
through simulation training.
Simulation can be used to address clinical issues of screening, diagnosis,
and management, but also non-technical issues such as communication
between obstetricians and anesthesiologists, escalation triggers,
communication with patients and families and many other unique
challenges.

36.  Biases in Diagnosis and Escalation:
Bias pervades and permeates our clinical diagnostic and management processes.
A few biases are particularly relevant for obstetric hemorrhage: one is confirmation
bias in which confirming evidence may be prioritized over disconfirming evidence to
support the thought of diagnosis.
The other bias is tolerance of ambiguity in which the ability of the provider to tolerate
ambiguous situations or contradictory information is variable from one provider to
another.

37. While we are currently working to uncover and study these biases there is no effective
way to eliminate them.
One promising solution is through choice architecture and forcing functions (e.g.
Calling a hemorrhage code is mandatory when the blood loss reaches a certain amount
or a certain number of medications have been given or when a Bakri balloon is
requested).

38.  Patient and Family Support:
The abrupt onset and the radical nature of certain treatments (e.g. Hysterectomy)
in the case of obstetric hemorrhage make it a perfect setting for patients and their
families to be ill-informed and psychologically unprepared to deal with the
situation at the time of the treatment and thereafter.
The permanent loss of function (e.g. fertility or kidney injury) or an organ (e.g.
Uterus) can be quite detrimental on the biological and psychological state of the
patient and her family.
Supporting patients and families during and after obstetric hemorrhage is an
essential component of taking holistic approach to patient care. Interventions
targeted at teaching providers how to deliver bad news and help with the
initial stages of grief can be helpful.

39. Conclusion and Next Steps:
 Obstetric hemorrhage with its related morbidities remains a
significant and often preventable cause of maternal morbidity
and mortality.
 Opportunities to further mitigate risk, while contributing to
improved patient outcomes, include helping to secure
necessary resources, building team training and
simulation programs, developing interventions targeted at
minimizing cognitive biases, and facilitating patient and
family support program development.
 There is a need for innovation and practice-changing
studies.

40.  At this stage, performance improvement and risk mitigation for obstetric
hemorrhage will require close coordination with clinicians and quality improvement
teams.
 We must establish standardized approaches to diagnosis and treatment through team
training and simulation that target both clinical and more importantly non-clinical
challenges, such as communication, escalation, and biases that can contribute to denial
or delay in recognition or management of obstetric hemorrhage.

41. References:
• Gonzalez-Brown V, Schneider P. Prevention of postpartum haemorrhage. Seminars
in Fetal and Neonatal Medicine, https://doi.org/10.1016/j.siny 2020.101129.
• Borovac-Pinheiro A, Pacagnella RC, Cecatti JG, et al. Postpartum hemorrhage:
New insights for definition and diagnosis. Am J Obstet Gynecol. 2018
Aug;219(2):162-8.
• Andrikopoulou M, DoAlton ME Postpartum hemorrhage: Early identification
challenges. Seminars in Perinatology. 2018; doi: https://doi.org/10.1053/j.semperi
2018.11.003
• Maul H, Maner WL, Saade GR, Garfield RE. The physiology of uterine
contractions. Clin Perinatol. 2003 Dec 30(4):665-76
• World Health Organization. WHO recommendations for the prevention and
treatment of postpartum haemorrhage. 2012. WHO: Geneva, Switzerland

42. • Sageer R, Kongnyuy E, Adebimpe WO, et al. Causes and contributory factors of
maternal mortality: Evidence from maternal and perinatal death surveillance and
response in Ogun state, Southwest Nigeria. BMC Pregnancy and Childbirth.
2019;19(1):63
• Geller SE, Goudar SS, Adams MG, et al. Factors associated with acute postpartum
hemorrhage in low-risk women delivering in rural India. Int J Gynaecol Obstet.
2008;101(1):94–9.
• Khadilkar SS, Sood A, Ahire P. Quantification of Peri-partum Blood Loss: Training
Module and Clot Conversion Factor. The Journal of Obstetrics and Gynecology of
India. 2016 Oct 1;66(1):307-14.
• FOGSI PPH Prevention and Management: Updated PPH Guidelines SEPTEMBER
2022

43. THANK YOU