Introduction

Post-partum bleeding ( PPH ) refers to an estimated blood loss in surplus of 500 milliliter following a vaginal birth and a loss greater than 1000 milliliter during a Cesarean subdivision. Major bleeding is defined as an estimated blood loss of more than 2500 milliliter or the transfusion of 5 or more units of blood or intervention of coagulopathy.

These values are arbitrary as ocular appraisal of blood loss is non dependable. Patients with a low organic structure mass index have a lower blood volume of 70 ml/kg and anemic adult females have fewer militias to defy blood loss and hence will decompensate Oklahoman. Therefore, a utile definition takes into history any blood loss that causes a major physiological alteration like a autumn in blood force per unit area, as the hazard of deceasing from PPH depends on the sum and rate of blood loss and the adult female ‘s wellness.

PPH is classified as primary and secondary. Primary PPH occurs within 24 hours of bringing and secondary PPH after 24 hours and within 6-12 hebdomads post-partum.

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Causes and hazard factors

PPH is normally due to one or a combination of four procedures referred to in the ‘4Ts ‘ mnemonic:

aˆ? tone ( post-delivery hapless uterine contraction )

aˆ? tissue ( blood coagulums and/or retained merchandises of construct )

aˆ? injury ( venereal piece of land )

aˆ? thrombin ( curdling abnormalcies ) .

Common hazard factors for PPH are an over-distended womb due to foetal macrosomia, multiple gestation and polyhydramnios. Antepartum bleeding, chorio-amnionitis, curdling upsets, fibroid womb, initiation of labor, instrumental bringing, fleshiness, preeclampsia, old Caesarean subdivision bringing, old history of PPH, primigravidity, drawn-out rupture of membranes and/or labor are besides considered to be risk factors.

There is a tendency in the UK towards detaining child-bearing. Increased maternal age, Caesarean and instrumental bringings and placenta praevia increase the incidence of PPH. An increasing figure of multiple gestations due to aided reproduction can besides ensue in an increased incidence of PPH.

PPH can happen in adult females without identifiable hazard factors. In absolute Numberss, more adult females without hazard factors have atonic PPH as compared with those with hazard factors.

Pathophysiology

The blood vass providing the placental bed base on balls through an interlinking web of musculus fibers of the myometrium. Myometrial contraction causes placental separation and causes blood vass to compress. This haemostatic mechanism or ‘living ligatures ‘ control the hemorrhage from the eutherian bed when the placenta separates. Uterine atony consequences in a failure of these ‘living ligatures ‘ to halt the hemorrhage. The active direction of the 3rd phase of labor is associated with a decrease in the hazard of PPH and less demand for blood transfusion by heightening the above physiological procedure.

Mild daze occurs when 20 % of the blood volume is lost, ensuing in reduced perfusion of non-vital variety meats and tissues ( i.e. bone, fat, skeletal musculus ) with picket and cool tegument. When 20-40 % of the blood volume is lost, moderate daze occurs with reduced perfusion of critical variety meats ( i.e. intestine, kidneys, liver ) , oliguria and/or anuresis, a bead in blood force per unit area, and mottling of the tegument in the legs. When 40 % or more of the blood volume is lost, terrible daze occurs ensuing in reduced perfusion of the bosom and encephalon, agitation, restlessness, coma, echocardiogram and EEG abnormalcies, and eventually cardiac apprehension.

Prevention of PPH

Merely 40 % of adult females who develop PPH have an identifiable hazard factor. Womans with hazard factors should be delivered in Centres with transfusion and intensive attention unit installations. The Royal College of Obstetricians and Gynaecologists ( RCOG ) urges early or contraceptive interventional radiology for the bar and direction of PPH in bad instances and recommends schemes for the direction of unannounced PPH.

Prevention of PPH includes prenatal hazard appraisal and intervention of anemia or other wellness jobs so that adult females are healthy plenty to defy PPH, every bit good as appropriate intra-partum and post-partum direction. The International Confederation of Midwives and the International Federation of Gynecology and Obstetrics ( FIGO ) have together launched a global programme to advance active direction of the 3rd phase of labor for all adult females. Active direction consists of intercessions designed to ease placental bringing by bettering uterine contractions and forestalling PPH by debaring uterine atonicity. These steps include disposal of uterotonic agents, controlled cord grip and uterine massage after bringing of the placenta, as deemed appropriate. This attack reduces the hazards of PPH, anemia, demand for blood transfusion, drawn-out 3rd phase of labor and usage of curative drugs for PPH. It is recommended that active direction should be everyday for adult females in pregnancy infirmaries and there is no grounds to propose that this recommendation should non include low-risk births at place or in birth Centres.

Oxytocin is used routinely in the active direction of the 3rd phase of labor. It is routinely administered for the bar and intervention of PPH as a first-line agent as it is effectual within 2-3 proceedingss after injection and, as it has minimum side effects, it can be used in all adult females. If Pitocin is unavailable, ergometrine maleate 0.5 milligram intramuscularly, ergometrine with oxytocin 5 IU/ml ( syntometrine ) or misoprostol 0.4 milligram orally can be used.

Misoprostol – which is a prostaglandin E1 parallel – can be administered by unwritten, sublingual and rectal paths. The chief side effects are diarrhoea, sickness and emesis. Rectal misoprostol causes less shaky and fever, than unwritten misoprostol. A recent Cochrane reappraisal on the usage of prostaglandins for the bar of PPH concluded that neither intramuscular prostaglandins nor misoprostol are preferred to conventional injectable uterotonics as portion of the direction of the 3rd phase of labor particularly for low-risk adult females.

Carbetocin is a long-acting oxytocin agonist and has been used for the bar of PPH. The advantage of intramuscular carbetocin over intramuscular Pitocin is its longer continuance of action. It induces a drawn-out uterine response post-partum, both in amplitude and frequence of contraction. Carbetocin is associated with decreased demand for other uterotonic agents and uterine massage, and there are no differences in side effects between carbetocin and Pitocin.

FIGO recommends that skilled birth attenders should utilize physiological ( or expectant ) direction of the 3rd phase if oxytocin or misoprostol are unavailable.

In 2006, the World Health Organization held a proficient audience on the bar of post-partum bleeding and it recommends the followers.

aˆ? Active direction of the 3rd phase of labor should include: disposal of an uterotonic shortly after the birth of the babe ; delayed cord clamping ; and bringing of the placenta by controlled cord grip followed by uterine massage.

aˆ? Active direction of the 3rd phase of labor should be offered by skilled attenders, as possible hazards such as uterine inversion, may ensue from inappropriate cord grip.

aˆ? Oxytocin should be offered for the bar of PPH in penchant to unwritten, sublingual or rectal misoprostol.

aˆ? In the absence of active direction of the 3rd phase of labor, an uterotonic drug ( oxytocin or misoprostol ) should be offered.

Management

A direction algorithm – HAEMOSTASIS – has been proposed to help bit-by-bit direction of atonic PPH. The undermentioned subdivision has been adapted from: Chandraharan E & A ; Arulkumaran S. Management algorithm for atonic postpartum bleeding. J Psychosom Obstet Gynaecol June 2005: 106-112 and Doumouchtsis SK, & A ; Arulkumaran S. Postpartum bleeding: changing patterns. In: Recent Progresss in Obstetrics and Gynaecology. Vol 24. Dunlop W, Ledger WL ( explosive detection systems ) . London: The Royal Society of Medicine Press Ltd ; 2008. pp. 89-104.

HAEMOSTASIS algorithm

General medical direction

Hydrogen

Call for aid

A

Assess ( critical marks, blood loss ) and revive

Tocopherol

Establish aetiology, ecbolics, guarantee handiness of blood

Establish aetiology: ‘4Ts ‘ – tone, tissue, injury, thrombin

Ecbolics ( syntometrine, ergometrine, bolus syntocinon )

Ensure handiness of blood and blood merchandises

Meter

Massage the womb

Oxygen

Oxytocin extract, prostaglandins ( endovenous, rectal, intramuscular, intramyometrial )

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Specific surgical direction

Second

Shift to runing theatre – two-handed compaction anti-shock garment, particularly if transportation is required

Thymine

Tissue and injury to be excluded and proceed to tamponade with balloon or uterine wadding

A

Apply compaction suturas

Second

Systematic pelvic devascularisation ( uterine, ovarian, quadruplicate, internal iliac )

I

Interventional radiology, uterine arteria embolisation

Second

Subtotal or entire abdominal hysterectomy

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H – Call for aid

Major PPH must be managed suitably by a multidisciplinary squad. Consultant accoucheurs, anesthesiologists, hematologists, accoucheuses, theatre staff, blood bank, hospital porters and even the intensive care/high dependence unit staff should be alerted.

A – Buttocks ( critical marks, blood loss ) and revive

Early acknowledgment, prompt resuscitation and Restoration of the go arounding blood volume are the constituents in the direction of PPH. General resuscitation steps include appraisal of the haemodynamic position by supervising the patient ‘s critical parametric quantities ( degree of consciousness, blood force per unit area, pulsation and O impregnation ) .

Accurate appraisal of the blood loss warns of impending hemorrhagic daze. Different methods of appraisal have been evaluated and guidelines to better truth of the ocular appraisal of blood loss have been suggested. Two big bore cannulae are inserted and blood samples taken for full blood count, group and salvage and cross-match, curdling screen and nephritic and liver profile.

Fluid resuscitation in PPH is frequently conservative because of underestimate of blood volume and rapid blood loss. It is of import to retrieve that symptoms of hypovolemia are frequently delayed due to compensatory mechanisms as these adult females are fit and immature. Concerns that fluid overload will take to pneumonic hydrops and cardiac failure, may be misdirecting. A loss of 1 liter of blood requires replacement with 4-5 liters of crystalloid ( 0.9 % normal saline or lactated Ringer ‘s solution ) or colloids until cross-matched blood is made available, as most of the endovenous fluid displacements from the intravascular to the interstitial infinite.

‘The aureate first hr ‘

Severe bleeding leads to cardiovascular failure if non diagnosed and treated efficaciously. As the badness depends on organic structure weight and metamorphosis and hemoglobin degrees, exigency steps should be initiated if the estimated blood loss is more than tierce of the adult female ‘s blood volume ( blood volume [ milliliter ] = weight [ kg ] A- 80 ) or more than 1000 milliliter or a alteration in haemodynamic position.

As more clip base on ballss between the oncoming of terrible daze and effectual resuscitation, the opportunities of survival lessening because metabolic acidosis sets in. The ‘golden first hr ‘ is the clip at which resuscitation must be commenced to guarantee the best opportunity of endurance. The chance of endurance lessenings aggressively after the first hr if the patient is non efficaciously resuscitated.

For the general acute direction of PPH a ‘rule of 30 ‘ has been proposed. If the patient ‘s systolic blood force per unit area ( SBP ) falls by 30 mmHg, bosom rate ( HR ) rises by 30 beats/min, respiratory rate additions to & gt ; 30 breaths/min and hemoglobin or hematocrit bead by 30 % , and/or her urinary end product is & lt ; 30 ml/hour, so the patient is most likely to hold lost at least 30 % of her blood volume and is in moderate daze taking to severe daze.

The usage of the ‘shock index ‘ ( SI ) is priceless in the monitoring and direction of adult females with PPH. It refers to HR divided by the SBP. The normal value is 0.5-0.7. With important bleeding, it increases to 0.9-1.1. The alteration in SI of an single patient appears to correlate better in placing early acute blood loss than the HR, SBP or diastolic blood force per unit area used in isolation.

E – Establish aetiology, ecbolics, guarantee handiness of blood

aˆ? Establish aetiology: 4Ts – tone, tissue, injury, thrombin

aˆ? Ecbolics ( syntometrine, ergometrine, bolus syntocinon )

aˆ? Ensure handiness of blood and blood merchandises

A systematic appraisal to place the cause of hemorrhage is made utilizing the ‘4Ts ‘ mnemonic. Thorough appraisal of the uterine tone is followed by uterine massage and disposal of uterotonic agents if the womb is atonic. Exploration of the uterine pit under anesthesia is indispensable to except or take retained placental tissue and membranes. If bleeding persists despite a well-contracted womb, scrutiny under anesthesia must include looking for cervical cryings or cryings in the vaginal vault, as these may affect the uterus and/or wide ligament and may be the cause of retroperitoneal hematoma. Pressure and/or packing are utile to accomplish hemostasis and to forestall hematoma formation. Suspect a curdling defect if retained tissue or injury is excluded and shed blooding continues despite a well-contracted womb.

Uterine atonicity is the most common cause of PPH. Medical direction consists of oxytocin 10 units by slow endovenous injection, ergometrine 0.5 milligrams by slow endovenous injection, methergine 0.2 milligrams intramuscularly, oxytocin extract, 15-methyl PGF2 intramuscularly or intramyometrially, or misoprostol.

If hemorrhage continues, blood transfusion must be commenced if the estimated blood loss is over 30 % of the blood volume or if the patient is haemodynamically unstable despite aggressive resuscitation. Group O, Rhesus-negative blood should be transfused until sorted and cross-matched blood is available.

Coagulopathy may be due to a figure of factors: disseminated intravascular curdling ( DIC ) ; depletion of coagulating factors within blood coagulums ( ‘washout phenomenon ‘ ) ; dilution of coagulating factors with crystalloid fluid resuscitation ; deficiency of coagulating factors in stored blood ; hypothermia ; and acidosis secondary to hypoxia. Dilutional coagulopathy occurs when about 80 % of the original blood volume has been replaced. One liter of fresh frozen plasma should be administered ( 15 ml/kg ) with every 6 units of blood transfused. Platelet concentration should be maintained at more than 50 A- 109 per liter or more than 80-100 A- 109 per liter if surgical intercession is likely. Cryoprecipitate ( which provides a more concentrated signifier of factor I ) and other coagulating factors ( VIII, XIII, von Willebrand factor ) may be required if there is DIC or if the factor I degree is less than 10 g/l.

M – Massaging the womb

Two-handed uterine massage ( vaginal manus in the anterior fornix and abdominal manus on the uterine fundus ) is a really effectual step and reduces shed blooding even if the womb remains atonic, leting resuscitation to be effectual and, therefore, cut downing farther blood loss.

O – Oxytocin extract, prostaglandins

Oxytocin, can be given as a slow endovenous bolus ( 5 units ) or as an extract ( 40 units in 500 milliliter of 0.9 % normal saline, infused at a rate of 100-125 ml/hour ) in order to keep uterine contraction. There are no absolute contraindications, but an antidiuretic consequence with volume overload can develop with high cumulative doses. If the womb remains atonic after initial oxytocic therapy, syntometrine or ergometrine can be repeated.

Ergometrine is an ergot alkaloid and high blood pressure and cardiac disease are contraindications due to the possible development of terrible high blood pressure and myocardial ischemia.

Carboprost is a prostaglandin F2 parallel administered intramuscularly or intramyometrially. It is a second-line agent for uterine atonicity ( 0.25 mg repeated every 15-20 proceedingss to a maximal dosage of 2 milligram ) . It is known to be 80-90 % effectual in diminishing blood loss due to PPH in instances that are stubborn to oxytocin and ergometrine. It is contraindicated in asthma as it is bronchoconstrictive and other side effects include diarrhea, purging, febrility, concern and flushing.

Misoprostol is a man-made prostaglandin E1 parallel and has been used in the direction of PPH. Placebo-controlled randomised tests compared misoprostol with placebo and showed that misoprostol usage was non associated with any important decrease of maternal mortality, hysterectomy, extra usage of uterotonics, blood transfusion, or emptying of maintained merchandises. Misoprostol was associated with a important addition of maternal fever and chill. However, an unblinded test showed better clinical response to rectal misoprostol than a combination of syntometrine and Pitocin. A recent Cochrane reappraisal concluded that the add-on of misoprostol with Pitocin is superior to the combination of Pitocin and ergometrine entirely for the intervention of primary PPH. As the extremum serum concentration of Pitocin is much smaller than unwritten misoprostol, which reaches its serum extremum concentration at 20 min, a combination of these two agents can supply a sustained uterotonic consequence.

A figure of instance studies of empirical ‘off-label ‘ usage of recombinant activated factor VII show that it may be an alternate haemostatic agent when the criterion intervention is uneffective.

The Scots Confidential Audit of Severe Maternal Morbidity recommends that, if conservative steps fail to command bleeding, surgical hemostasis should be commenced ‘sooner instead than subsequently ‘ . Other studies from the RCOG recommend that accoucheurs must see all available intercessions to halt bleeding including B-Lynch sutura, uterine arteria embolisation or even extremist surgery.

Recommendations have been made that all infirmaries with bringing units should take to supply an exigency interventional radiology service as these have the possible to salvage the lives of patients with monolithic PPH.

The American College of Obstetricians and Gynecologists suggests that uterine tamponage can be effectual in diminishing bleeding secondary to uterine atonicity, and processs such as uterine arteria ligation or B-Lynch sutura may be used alternatively of the demand for hysterectomy. In patients with stable critical marks but relentless hemorrhage, arterial embolisation is suited, particularly if the rate of blood loss is non inordinate.

S – Shift to runing theater ( anti-shock garment, particularly if transportation is required and two-handed compaction )

In place births and midwifery-led units, transportation to a Centre with greater installations is indicated at this phase. A new type of non-pneumatic anti-shock garment ( NASG ) can change by reversal the consequence of daze on the organic structure ‘s blood distribution by using external counter force per unit area to the legs and venters and returning blood to the critical variety meats, therefore maintaining the adult female stabilised until she reaches a infirmary.

A pilot survey showed that in adult females in whom the NASG was used, compared with adult females in a control group, shed blooding decreased by 50 % in those sing assorted signifiers of obstetric bleeding ( e.g. post-abortion complications, PPH or ruptured ectopic gestation ) . The usage of this device could be critical in cut downing maternal mortality in low-risk countries where making a wellness installation could take clip.

T – Tissue and injury to be excluded and proceed to tamponade with balloon or uterine wadding

Continuous shed blooding indicates transportation to and rating in the operating theater. Examination with appropriate lighting, equipment, analgesia and aid licenses appraisal of the uterine tone and excludes retained tissue and injury. Two-handed uterine compaction helps to command shed blooding while monitoring and resuscitation continues and readyings are made for farther intercessions.

Uterine wadding has ever been considered effectual, speedy and safe for commanding PPH. The usage of uterine wadding in the direction of PPH fell into discredit in the 1960s following concerns that it: ( I ) was potentially traumatic and time-consuming ; ( two ) might hide on-going bleeding ; ( three ) might predispose to the development of infection ; and ( four ) represented a ‘non-physiological attack ‘ . More late, surveies concluded that uterine wadding is a safe, speedy and effectual process for commanding PPH.

Successful usage of uterine balloon tamponage has been reported utilizing a figure of devices, including a Bakri balloon, a rubber, a Foley ‘s catheter, the Rusch urological hydrostatic balloon and the Sengstaken-Blakemore oesophageal catheter ( SBOC ) . The SBOC has been the most often used and reported device.

Overall, the reported success rates vary between 70 % and 100 % . Uterine tamponage with the SBOC has been described as a predictive trial in obstetric bleeding. The ‘tamponade trial ‘ has had a positive consequence of & gt ; 87 % for the successful direction of PPH in these surveies.

The ‘tamponade trial ‘ apprehensions shed blooding in most adult females with terrible PPH and allows the obstetrician to place adult females necessitating a laparotomy. This method has the advantages that: ( I ) interpolation is easy and rapid with minimum anesthesia ; ( two ) it can be performed by comparatively inexperient forces ; ( three ) remotion is painless ; and ( four ) failed instances can be identified quickly. The early usage of balloon tamponage consequences in decreased entire blood loss and haemorrhage-related maternal mortality. No immediate jobs ( such as hemorrhage and sepsis ) or long-run complications ( such as catamenial and birthrate jobs ) have been reported in adult females who have undergone uterine tamponage.

A – Using the compaction suturas

If the patient is stable and two-handed compaction of the womb has successfully achieved hemostasis, so compaction suturas may be of value. Assorted alterations have been reported to the original B-Lynch sutura technique ( Figure 1 and Figure 2 ) . The major advantages are easy application of such suturas and saving of birthrate. The disadvantage is the demand for laparotomy. Recognized complications include eroding through the uterine wall, pyometra and uterine mortification.

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Figure 1.A The B-Lynch sutura. Reproduced with permission from Sapiens Publishing, 2006.

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Figure 2.A Reproduced with permission from Sapiens Publishing, 2006. a Cho ‘s multiple square technique. b Vertical and horizontal compaction suturas.

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S – Systematic pelvic devascularisation

Pelvic devascularisation requires laparotomy, and progressive, step-wise devascularisation, whereby the uterine, ovarian and internal iliac arterias are ligated ( Figure 3 ) . Internal iliac arteria ligation ( Figure 4 ) is effectual in collaring hemorrhage from within the venereal piece of land, nevertheless, it takes clip, is technically ambitious and carries the hazard of hurt to neighboring constructions.

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Figure 3.A Quadruple ligation. Reproduced with permission from Elsevier Publishers, 2008 ( Chandraharan E & A ; Arulkumaran S. Surgical facets of postpartum bleeding. Best Practice & A ; Research Clinical Obstetrics and Gynaecology, 2008 ) .

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Figure 4.A Internal iliac arteria ligation: anatomy of the sidelong pelvic wall. Reproduced with permission from Elsevier Publishers ( Chandraharan E & A ; Arulkumaran S. Surgical facets of postpartum bleeding, Best Practice & A ; Research Clinical Obstetrics and Gynaecology, 2008 ) .

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Prerequisites include a haemodynamically stable patient, specialist surgical expertness and a patient ‘s desire to continue her future birthrate. The reported success rates are between 40 % and 100 % . When arterial ligation fails, hysterectomy follows and has a higher morbidity compared with those patients undergoing hysterectomy without old efforts at arterial ligation.

I – Interventional radiology and uterine arteria embolisation

Arterial embolisation under fluoroscopic counsel was first described in 1979. The success rate is every bit high as 70-100 % and the process has the possible to continue birthrate. Contraceptive embolisation has a function in an elected Caesarean subdivision when the placenta is thought to be morbidly adherent.

Complications include haematoma formation, infection, contrast-related side effects and ischemia, ensuing in uterine and vesica mortification. Specialized equipment and an interventional radiotherapist with a great grade of expertness are prerequisites for this process.

A recent systematic reappraisal failed to show that any one method for the conservative direction of terrible PPH was superior to another. The reappraisal recommended that uterine balloon tamponage should be considered as the first measure in the direction of intractable PPH, which is non due to venereal injury or retained tissue, and which does non react to medical intervention. The pick of steps employed depends on the available installations and the grade of ongoing hemorrhage, the estimated blood loss and the haemodynamic province of the adult female.

S – Subtotal or entire abdominal hysterectomy

Subtotal or entire abdominal hysterectomy is normally a last resort in the direction of PPH and must non be delayed if the conservative steps have failed to command it. Subtotal hysterectomy may non be effectual when the beginning of the hemorrhage is in the lower section, neck or vaginal fornices. Hysterectomy is associated with legion postoperative complications ( e.g. bowel hurt, fistulous withers formation, pelvic hematoma, sepsis, urinary piece of land hurt, vascular hurt ) . The attendant loss of child-bearing and its psychological effects must non be underestimated.

All these surgical techniques ( uterine tamponage, devascularisation, compaction suturas and hysterectomy ) require the ready handiness of specific instruments and equipment. For this, an obstetric bleeding equipment tray on labour ward facilitates prompt surgical direction of terrible obstetric bleeding, and reduces the demand for blood transfusion and hysterectomy.

Decisions

PPH is a major cause of maternal morbidity and mortality. Designation of hazard factors antenatally and intra-partum is utile in the bar and intervention of PPH. Catastrophic and dangerous bleeding is frequently unpredictable. Prompt resuscitation of the patient with effectual Restoration of the go arounding blood volume and designation of the cause of hemorrhage should be performed in a multidisciplinary squad scene. Rapid and prompt intervention steps should be instituted in a step-wise mode utilizing the algorithm ‘HAEMOSTASIS ‘ and assessment tools such as the ‘rule of 30 ‘ and the ‘shock index ‘ . Protocols for the bar and direction of PPH should be invariably updated in every pregnancy unit. The preparation of all members of staff in the direction of this common obstetric exigency should include regular ‘fire drills ‘ .

aˆ? Specific direction of commanding PPH should travel manus in manus with fluid, blood and coagulating factor resuscitation

aˆ? Every unit should hold a protocol to pull off PPH in a stepwise mode

aˆ? Medical direction should predate surgical direction

aˆ? Simple surgical direction ( tamponage, brace suturas ) is less time-consuming, can be done with minimum preparation and is effectual in more than 80 % of instances

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