Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Postpartum haemorrhage (PPH), defined as blood loss ≥500 ml, is a major cause of maternal mortality and morbidity worldwide. For every death, 20 women live with the consequences of associated morbidities, with the greatest burden in low‐income countries. PPH is a common emergency, and readily treatable when appropriate resources are available.[1]. Severe PPH (variously defined from 1000ml upwards) has been used as a measure of severe morbidity. Despite surgical, medical and training innovations, PPH rates remain high in several countries. The causes are likely to be multifactorial with shifting demography and health status widely cited, e.g. age, obesity, comorbidity, multiple pregnancy and ethnicity.[2-4].

A better understanding of the factors associated with PPH maternal mortality is critical for preventing the risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women’s characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals. This prospective observational study aimed to: (i) measure PPH incidence; (iii) identify chronologically ordered risk factors (pre‐existing or acquired) for PPH and progression to severe PPH. Identifying risk pathways is important as predisposing risk can underlie factors that appear, accumulate and dominate later events, including subsequent pregnancies. Judicious use of uterotonics, aggressive approach, application of B lynch suture and timely arrangement of blood and blood products is essential. [3-8].

• Duration and type of study: This is a prospective observational study. The causes are likely to be multifactorial with shifting demography and health status widely cited, e.g. age, obesity, comorbidity, multiple pregnancy ethnicity etc.
• Setting: Hospital setting
• Sampling methods: Patients shifted from OT to ICU and for how long. The patients with severe blood loss needed blood transfusions and other blood products like FFP, platelets etc.

After many infrastructural changes and increase in beds, now the gynaecology department is strengthened and number of cases likely to increase.

The above chart shows the trend in both the years as far as obs &gynae cases are concerned. It is almost similar and shows the no. of LSCS and normal deliveries.

This chart shows the total no. of deliveries and incidence of PPH in two year period

The ICU is one of the best in the city and therefore all types of high-risk obstetrics is being taken here.5 patients were shifted last year whereas this year it was only 2 patients, showing improvement in care.

Due care preoperatively with timely management necessitated blood transfusion only in one patient this year whereas blood transfusion was required in 4 patients last year.

The three highest-ranked uterotonic agents for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, misoprostol plus oxytocin

A prospective observational study was done by Briley A et al on reporting errors, incidence and risk factors for postpartum haemorrhage (PPH) (≥500 ml) and progression to severe PPH (≥1500 ml). Sequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date.Gallos ID et al did a network meta‐analysis on uterotonic agents for preventing postpartum haemorrhage. Objectives were to identify the most effective uterotonic agent(s) to prevent PPH with the least side effects, and generate a ranking according to their effectiveness and side‐effect profile. The network meta‐analysis included 196 trials (135,559 women) involving seven uterotonic agents and placebo or no treatment, conducted across 53 countries (including high‐, middle‐ and low‐income countries). The three highest-ranked uterotonic agents for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, misoprostol plus oxytocin combination and carbetocin. There is evidence that ergometrine plus oxytocin (RR 0.70, 95% CI 0.59 to 0.84, moderate certainty), carbetocin (RR 0.72, 95% CI 0.56 to 0.93, moderate certainty) and misoprostol plus oxytocin (RR 0.70, 95% CI 0.58 to 0.86, low certainty) may reduce PPH ≥ 500 mL compared with oxytocin. [2,3].

High‐certainty evidence suggests that misoprostol is less effective in preventing PPH ≥ 1000 mL when compared with oxytocin (RR 1.19, 95% CI 1.01 to 1.42). Despite the comparable relative treatment effects between all uterotonics (except misoprostol) and oxytocin, ergometrine plus oxytocin, misoprostol plus oxytocin combinations and carbetocin were the highest-ranked agents for PPH ≥ 1000 mL. The two combination regimens were associated with important side effects. When compared with oxytocin, misoprostol plus oxytocin combination increases the likelihood of vomiting (RR 2.11, 95% CI 1.39 to 3.18, high certainty) and fever (RR 3.14, 95% CI 2.20 to 4.49, moderate certainty). Ergometrine plus oxytocin increases the likelihood of vomiting (RR 2.93, 95% CI 2.08 to 4.13, moderate certainty) and may make little or no difference to the risk of hypertension, however absolute effects varied considerably and the certainty of the evidence was low for this outcome. All agents were generally effective for preventing PPH when compared with placebo or no treatment. Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination may have some additional desirable effects compared with the current standard oxytocin.

Early resort to IIAL effectively prevents hysterectomy in women with atonic PPH. In traumatic PPH, IIAL facilitates hysterectomy or repair as indicated and prevents reactionary haemorrhage.[7]. McCormick ML reviewed the literature to determine the most effective methods for preventing postpartum hemorrhage (PPH), the single most important cause of maternal death worldwide. A review of the literature confirms that active management of the third stage of labour, especially the administration of uterotonic drugs, reduces the risk of PPH due to uterine atony without increasing the incidence of the retained placenta or other serious complications. Oxytocin is the preferred uterotonic drug compared with syntometrine, but misoprostol also can be used to prevent haemorrhage in situations where parenteral medications are not available (e.g. at home births in developing countries). The use of active management of the third stage of labor to prevent PPH due to uterine atony should be expanded, especially in developing country settings. [8].

Similar were studies done by Tort J et al who did a cross-sectional epidemiological survey on factors associated with postpartum hemorrhage and maternal death. A better understanding of the factors associated with PPH maternal mortality is critical for preventing the risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women’s characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals. They suggested that anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality. [9].

Grönvall M et al did a retrospective case series on the use of Bakri balloon tamponade in the treatment of postpartum hemorrhage. Massive postpartum hemorrhage (PPH) is one of the most serious complications during delivery. Among the women treated with BBT, the cause of PPH was uterine atony (16%), cervical rupture (14%), vaginal rupture and/or paravaginal hematoma (22%), placenta previa (18%) and placental retention (30%). The overall success rate was 86%.

Proximately, PPH results from the failure of the placenta to separate from the uterine wall properly, most often because of impairment of uterine muscle contraction.

It was argued that vulnerability to PPH stems from the intensely invasive nature of human placentation. The human placenta causes uterine vessels to undergo transformation to provide the developing fetus with a high plane of maternal resources; the degree of this transformation in humans is extensive. It was seen that the particularly invasive nature of the human placenta increases the possibility of increased blood loss at parturition. [14].

Kwast BE et al studied postpartum haemorrhage and its contribution to maternal mortality. Whereas Knight M et al studied trends in postpartum hemorrhage in high resource countries. Our study was very much similar to the above studies and inference derived matched with the observations of the above authors. [15,16].

Potential risk factors should be negated and new risk factors such as increased duration of labor, obesity and changes in second and third stage management practice should be revised. Training should be provided to all staff involved in maternity care concerning the assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes.

Clinicians should be more vigilant given the possibility that the frequency and severity of PPH have increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.

First and Corresponding author: Dr. Neelima Agrawal : Data collection and statistical analysis. Second author Dr. P. N. Agrawal: Concept and data collection