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Objective Despite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH, would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion. Methods We reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH. Results Of 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively. Conclusion In this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.

Objective The primary objective was to describe the incidence of post-partum hemorrhage at cesarean delivery before and after implementation of a new high dose oxytocin protocol at Chris Hani Baragwanath Academic Hospital. Methods This was a cross sectional retrospective record review 3 months before and 3 months after the implementation of a high dose oxytocin protocol. The study included all women that underwent cesarean delivery between 1 November 2016 and 30 April 2017 with a gestation of >24 weeks. Results A total of 4604 Cesarean deliveries were performed during the study period, 2162 before the implementation of the new protocol and 2442 after. The incidence of post-partum hemorrhage was 4.8% (n = 91) in the Before group and 3.9% (n = 89) in the After group (P = 0.17). There was a 17.9% change in incidence of postpartum hemorrhage between the groups (P = 0.17). There was no significant difference in uterine atony between the Before and After groups (21.8% and 30.1%, P = 0.30). Conclusion There was no difference in the incidence of postpartum hemorrhage at cesarean delivery after the implementation of a high dose oxytocin protocol.

Objective: To determine the better route of prostaglandin F2α either intramyometrial or intramuscular for the management of uterine atony and to prevent surgical intervention. Study Design: Randomized Controlled Trial. Settings: Bahawal Victoria Hospital. Period: Feb 2018 to July 2018. Material & Method: A total of 266 patients with primary PPH due to uterine atony of 20 to 39 years of age were enrolled in the study. Patients of primary PPH due to bleeding disorders, ruptured uterus, on anticoagulant therapy and hypersensitivity to prostaglandin were excluded. Patients were divided randomly into two groups i.e. Group A (for intramyometrial injection) & Group B (for intramuscular injection). Outcome variables like arrest of bleeding within 30 minutes after start of treatment (efficacy) were noted for successful or unsuccessful outcome. Results: The mean age of women in group A was 26.94 ± 4.43 and in group B was 26.21 ± 4.09 years (p=0.005). The mean parity in group A was 2.92 ± 0.87 and in group B was 2.93 ± 0.98 (p=0.8579). Efficacy was 82.71% in group A (Intramyometrial group) and 91.73% in group B (Intramuscular group) with p-value of 0.0276. Conclusion: This study concluded that intramuscular prostaglandin F2α has better efficacy i.e. 91.73% in a patient of uterine atony for management of primary PPH as compared to intramyometrial rout of administration for prostaglandin F2α.

Background: Maternal mortality rate (MMR) is an important indicator that describes the health status and welfare of the people in a nation. WHO estimates MMR in the world every day is at 817 people. Maternal mortality is mostly caused by complications during pregnancy, childbirth, and postpartum where these complications are direct obstetric complications. Postpartum hemorrhage is the main cause of maternal death. Factors causing postpartum hemorrhage are uterine atony, retained placenta, laceration of the birth canal, and blood disorders. The delay in diagnosis and treatment of postpartum hemorrhage is mostly caused by the estimated volume of blood loss in labor that is too low and the lack of equipment or clinical skills to solve the problem. Errors in calculating the volume of bleeding lost during delivery are too late to recognize bleeding that can lead to death due to lack of skills to prevent and treat postpartum hemorrhage. Research objective to determine the effectiveness of the product (mattress) in measuring blood loss in maternity. Research Method: The type of research used was experimental research, namely one shot case study. The study was conducted in two Independent Midwife Practices located in the city of Pontianak, West Kalimantan, Indonesia from May to September 2021. The subjects of the study were maternity mothers and birth attendant midwives with a consecutive sampling technique of 30 samples divided into 3 groups with 10 samples respectively of each product. The instrument used to collect data was a questionnaire with a Likert scale which was distributed to maternity mothers as direct users of the mattress and midwives who helped use the mattress. Statistical analysis used was one way ANOVA test. Research results Based on the one way ANOVA test, it was found that the average assessment given by patients and midwives on the three mattress models had a significant difference with a p value of 0.000. In the Post Hoc Turkey HSD test, it was found that there was no difference in the mean of patient assessments between model 1 and model 2 with p value = 0.239. The case was different between model 1 and model 3 and model 2 and model 3, namely, there was a significant difference. Model 1 and model 3 have a p value = 0.009 with an average difference of 2,700 while model 2 and model 3 have a p value = 0.000 with an average difference of 4,100. In the Post Hoc Turkey HSD test, there was a significant difference in the average of the midwives' assessments on the three mattress models. Model 1 and model 2 have a p value = 0.000 with an average difference of 5,800, model 1 and model 3 have a p value = 0.000 with an average difference of 6,900, while model 2 and model 3 have a p value = 0.000 with an average difference of 12,700. Keywords: [Maternity bleeding, Measuring mattress].

Treatment methods for managing uterine atony include uterine compression sutures such as B-Lynch compression suture [1]. Christopher B-Lynch and colleagues first reported this technique in 1997 [2]. Following this, other types of compression sutures, such as modified B-Lynch, Hayman, Pereira, Ouahba, Hackethal, or Cho suture, have proliferated [3, 4].

Background: Hemostasis is an integral and very important aspect of surgical practice. In the developing world, about 1.2% of deliveries are associated with PPH and when PPH occurred about 3% of women died. Causes of postpartum hemorrhage are uterine atony, trauma, retained placenta or placental abnormalities, and coagulopathy, commonly referred to as the "four Ts". Objective: To study the effect of gelfoam in hemostasis as adjuvant in control of primary postpartum hemorrhage. Patients and Methods: This was a Cohort study conducted at Sayed Galal University Hospital, Al-Azhar University Faculty of Medicine during the period from May 2019 to May 2020. A number of 60 cases of postpartum hemorrhage and role of gel foam in hemostasis as adjuvant in control of primary postpartum hemorrhage. Results: The findings of the present study indicate that local hemostatic agent “gel foam” was useful as adjuvant in control of primary postpartum hemorrhage in cesarean section. Local hemostats reduce the use of systemic hemostats, shorten the time required to achieve hemostasis. The delay in the recovery of bowel motility was due to the local hypersensitivity reaction caused by gelatin sponge and/or dislocation of this local hemostat. Conclusion: Local hemostatic agent “gel foam” was useful in adjuvant in control of primary postpartum hemorrhage in cesarean section.

Mortality due to cardiovascular disease in pregnancy is a growing problem in developed countries, being nowadays the leading cause of maternal death. Within this group, the most common cause of death are congenital or acquired heart diseases, representing a challenge in the management of these patients, since the pregnancy-related physiological alterations can impair their basal condition and treatment. We present the case of a 34-year-old patient, without any relevant pathological antecedents, who developed a second-degree atrioventricular block, Mobitz type I, following the administration of methylergometrine during cesarean section due to failure to progress in labour. We emphasize the importance of considering the side effects of commonly used drugs in pregnant patients, despite rare possibility of some adverse reactions.

The article presents the analysis of the causes of massive obstetric hemorrhages, treatment features, possible errors made during conservative and surgical treatment. The main causes of massive obstetric hemorrhage were postpartum uterine atony, abruption of a normally located placenta and placenta previa. The amount of lost blood averaged 2,410.45 ± 520.55 ml. The errors made during the clinical examination, surgical, conservative treatment and organizational issues led to 5 cases of maternal mortality and deterioration in the quality of life of women in the study group., В статье приводятся анализ причин массивных акушерских кровотечений, особенности лечения, возможные допущенные ошибки консервативного и оперативного лечения в ретроспективной группе исследуемых пациентов на базе областного перинатального центра в г. Ургенче Хорезмской области в Республике Узбекистан., У статті наводяться аналіз причин масивних акушерських кровотеч, особливості лікування, можливі допущені помилки консервативного і оперативного лікування в ретроспективній групі досліджуваних пацієнтів на базі обласного перинатального центру в м. Ургенчі Хорезмськой області в Республіці Узбекистан.

Postpartum haemorrhage (PPH) has been more common over the last three decades, accounting for 11% of all pregnancy-related deaths in the United States. In the third stage of labour, risk classification and active management are crucial preventative techniques. To avoid negative effects, a multidisciplinary approach to PPH patient care is required. To treat uterine atony, uterotonic medicines like oxytocin are used in combination with manipulative procedures like uterine massage and balloon tamponade. The amount of blood loss, duration of the third stage, need for MRP, incidence of PPH, need for repeated oxytocics, and its side effects were measured in Group I 100 women who were administered injection oxytocin 10 IU injection methergin 0.2 mg IV within one minute of the baby's delivery. The mean blood loss at vaginal delivery in Group I was 100-150 ml and in group I P value 0.027, which was statistically significant .In Group II was 160-200 ml with P value 0.036, which was statistically significant. The mean duration of third stag labour in Group 1 was 124.6 min and Group 2 was 144.8 min intravenous methergin is a better uterotonic when compared to intramuscular oxytocin to reduce the amount of blood loss at delivery and prevent complications like atonic PPH.

Background: one of the causes of direct maternal death related to childbirth is bleeding (28%). Perineal rupture is the most common cause of post partum hemorrhage after uterine atony. One way to reduce perineal rupture is to do perineal massage to train and stretch the perineal tissue to make it more soft and elastic. Objective: to determine the effect of perineal massage on the incidence of perineal rupture in labor. Methods: This study was a quasi-experimental design with an "Equivalent control group design" approach. The population in this study were all trimester III primigrvida pregnant women at Nene Mallomo Hospital, Sidenreng Rappang Regency. Sampling using purposive sampling technique, as many as 20 people were divided into two groups, namely 10 people in the intervention group and 10 people in the control group. Data collection using SOP, observation sheet and partograph then the data is processed and analyzed using computer (SPSS) version 20. Data analysis includes univariate analysis by looking for frequency distribution, bivariate analysis with Wilcoxon test with significance level α (0.05). Results: based on the results of statistical tests using Willcoxon, the results obtained p = 0.027

This study evaluated the association between timing and indication for previous cesarean section (C-section) and its association with postpartum risks for adverse maternal outcomes, primarily postpartum hemorrhage (PPH) in vaginal birth after cesarean (VBAC). This retrospective case–control study examined women following term vaginal delivery in a university-affiliated medical center between 2008 and 2018. Postpartum complications were compared between women who had their first VBAC and a control group comprised of women who had vaginal delivery without prior C-section. Additional analysis was performed to evaluate the association between the timing of previous C-section and the severity of postpartum adverse outcomes. Of the women meeting the inclusion criteria (n = 2879), 1,455 had VBAC and 1,424 were in the control group. Overall, significant postpartum complications, primarily PPH, were observed in the VBAC group compared to controls. Women who underwent C-section during second-stage of labor experienced higher PPH rates and increased drop in hemoglobin levels compared to women who underwent C-section during the first stage of labor or an elective C-Sect. (4.3 ± 0.9 g/dL vs. 2.8 ± 1.1 g/dL vs. 2.4 ± 0.8, p = 0.033). Concomitant increased need for blood transfusion (8.1% vs. 3.5% vs. 2.9%, respectively, p

Background: PPH which is 500 ml or more blood loss in 24 hours of birth . Uterine atony has been the commonest cause of PPH. To prevent PPH uterotonics like oxytocin and misoprostol should be given. Intravenous route of oxytocin has rapid effect, but is associated with cardiovascular side effects like rise in heart rate and decrease in blood pressure. Slower rate of absorption, lower peak levels and reduced adverse effects is seen with misoprostol given rectally when compared to sublingual and oral routes. This study aims to compare the effectiveness of transrectal misoprostol and intravenous oxytocin in preventing post-partum haemorrhage. Objectives: To compare the effectiveness of 600mcg transrectal misoprostol with 10IU intravenous oxytocin in active management of third stage of labour in preventing PPH and recommend technique for active management of third stage of labour in preventing PPH. Methodology: Women randomized into two groups for prevention of PPH and are given 600ug of misoprostol per rectally and 10IU oxytocin intravenously. Duration of third stage, the blood volume in kidney tray and additional blood loss in sterile surgical pads for 24hrs will be noted. The blood loss due to episiotomy will be taken as 50ml.Need of additional uterotonics(oxytocin or misoprostol), blood transfusion, removal of placenta manually, haemoglobin before and after delivery will be noted. Monitoring of patients for vital signs, uterine tone, fundal height and vaginal bleeding for 2 hour will be done. Result: The expected outcome of the study will be a significant difference in the blood loss during third stage of labour and 24 hours in post-partum period when uterotonics like oxytocin or misoprostol are used in managing third stage of labour actively. Conclusion: Our study will show the effect of intravenous oxytocin and transrectal misoprostol in managing third stage of labour actively to prevent post-partum hemorrhage.

OBJECTIVES To evaluate uterine tamponade devices' effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols. SEARCH STRATEGY PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021. STUDY SELECTION Randomised and non-randomised comparative studies. OUTCOMES Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy. RESULTS All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom-catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76-7.14) and hysterectomy (RR 4.14, 95% CI 0.48-35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07-15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47-41.09) with the use of the condom-catheter or surgical glove balloon. One non-randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11-1.03) and hysterectomy (RR 0.49, 95% CI 0.04-5.38) after the inclusion of the Bakri balloon. The second non-randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32-2.81) and hysterectomy (RR 1.84, 95% CI 0.44-7.69) after the inclusion of Ebb or Bakri balloon. CONCLUSIONS The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting. TWEETABLE ABSTRACT Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

Background: Every day more than 220 women around the world die from severe bleeding after childbirth. Globally post-partum hemorrhage is the number one direct cause of maternal mortality. Most postpartum hemorrhages are caused by uterine atony and occur in the immediate postpartum period. Most of these tragic deaths can be prevented by active management of third stage of labour. Active management of the third stage of labor should be practiced routinely to decrease the risk of postpartum hemorrhage. Oxytocin is used for enhancing uterine contraction after delivery. But oxytocin has some limitations like shorter half- life, less contraction time and more side effects, whereas carbetocin has prolonged duration of action which ensures more contraction time and less adverse effects. This study was done to see the efficacy and safety of carbetocin over oxytocin for prevention of PPH after vaginal delivery. Methodology: A randomized controlled clinical trial was conducted in the Department of Obstetrics and Gynecology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh over a period of 9 months from January 2015 to September 2015. Ninety four patients undergoing vaginal delivery at term were randomized into two groups receiving either 10IU oxytocin or 100 μg carbetocin. Outcome measures such as primary PPH, massive blood loss, need for additional uterotonic drug, additional blood transfusion as well as adverse effects were documented. Results: In this study, massive blood loss did not occur none of patients in carbetocin group. But massive blood loss occured 6.4% women of oxytocin group. Further fundal massage , immediate blood transfusion and additional uterotonics didn’t need any patient in carbetocin group. In oxytocin group, fundal massage required in 8.5% of women, blood transfusion needed in 10.6% patients and additional uterotonics needed in 10.6% women. Average amount of blood loss was 88 ml less in carbetocin group and adverse effects of drugs were almost similar in both group. Primary PPH developed in oxytocin group 8.5% but none of patients had developed PPH in carbetocin group. Conclusion: Carbetocin is an effective new drug than oxytocin for prevention of postpartum hemorrhage in vaginal delivery. Bioresearch Commu. 7(1): 927-931, 2021 (January)

Prenatal repair of fetal spina-bifida in the 2nd trimester has been shown to improve neurological function after delivery of the baby. Surgery can be performed with partial delivery of the fetus through a uterine incision, or increasingly via fetoscopy. Trocars to allow surgical instrumentation are introduced either via the exteriorized uterus or percutaneously. Both approaches require maternal anesthesia, an immobile anesthetized fetus and a non-contracting uterus. This can be achieved with administration of a general anesthetic to the mother, transplacental anesthesia of the fetus and tocolytic agents as required. Transplacental anesthesia needs to balance adequate depth of anesthesia for the mother and fetus with rapidly reversible uterine atony. The anesthetist is responsible for the safety of both patients. Monitoring of cardio-respiratory parameters for the mother are well established, but the tools available to monitor fetal well-being and access for corrective therapy are limited. Cardiotocography, fetal echocardiography or ultrasound assessment of umbilical or middle cerebral artery blood flow can be monitored for fetal well-being, but interpretation can be difficult. Fetal blood pressure monitoring is not yet feasible. There is a clear need to enhance fetal monitoring and define normal parameters with clear protocols for intervention to improve fetal safety. Abandoning the procedure should be considered to avoid emergency delivery of an extremely premature fetus. More research into suitable fetal monitoring techniques are needed.

Objective Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide. Uterine atony is the most common cause of bleeding accounting for ∼80 % of cases of postpartum hemorrhage. To reduce maternal morbidity and mortality due to bleeding caused by uterine atony even under limited resources, a simple and effective procedure that can be easily applied by all obstetricians and junior physicians is required. The aim of this study was to evaluate the efficacy of novel three vertical compression sutures for severe postpartum hemorrhage. Design Two vertical sutures are transfixed, one on each side of the lower uterine segment, from anterior to posterior over the bladder reflection avoiding the endometrial cavity, and tied over the fundus. The lateral sutures should be placed approximately 2 cm from the lateral edge of the lower uterus and approximately 4 cm from the cornual border, because the uterus widens upward from below. The third vertical suture is placed in the midline at the same level as the two vertical sutures, passing the endometrial cavity from anterior to posterior, and is tied in the middle of the fundus, where the three sutures are positioned side-by-side. Results We report 25 cases of postpartum hemorrhage secondary to life-threatening severe uterine atony treated with this novel approach of using three vertical compression sutures. Success was achieved in 24/25 (96 %) of cases treated with three vertical sutures, without requiring hysterectomy except one. Conclusions To reduce maternal morbidity and mortality, three vertical compression sutures as a novel technique, can be attempted before applying other more complex interventions. It does not require any extra skill or training, and is an ideal option as its simplicity allows it to be performed by all obstetricians, including junior obstetric staff.

Recently, the active management of the third stage of labor hasbecome a routine practice. In this study we compared two different ecobolics which were oxytocin and methyl ergometrinethrough intra-umbilical route. The method: the trial divided theincluded pregnant full term (>37 weeks) women in two groupsrandomly; one for 0.2 mg methyl ergometrine and the second 10units oxytocin. The outcomes were on the short term; estimatedblood loss (EBL), the need to add another ecobolic, vomiting,blood pressure changes and the duration of the third stage, andthe long-term outcomes were hemoglobin levels and the needfor surgical or medical uterine evacuation. The results: the meanblood loss was 155± 50.45ml and 167± 45.76 in the methyl ergometrine and the oxytocin groups respectively. Three cases inthe oxytocin group (3%) required additional methyl ergometrinewhile in the ergometrine group only one case was given an additional oxytocin (1%). No vomiting was reported in both groupsand there were trivial changes in blood pressure. In the oxytocin group, the third stage duration was average 3.03± 1.02 minin comparison to 2.98± 1.54min in the ergometrine group. Neither did those cases who were injected methyl ergometrine havesignificant changes in the hemoglobin levels nor did they needuterine evacuation. However, only one case in the oxytocin siderequired blood transfusion due to uterine atony. Conclusion: intra-umbilical methyl ergometrine should be considered as an effective safe ecobolic in the third stage of labor.

Importance Postpartum hemorrhage (PPH) is an emergent obstetric complication and the leading cause of maternal mortality. Pelvic arterial embolization (PAE) is an effective treatment for intractable PPH. However, a unique protocol has not been accepted in obstetrical practice. Objective To evaluate its efficiency, safety, complications, and outcomes, we conducted a systematic review and meta-analysis of PAE for PPH in the literature. Evidence Acquisition The Medline, the database of abstract of reviews, the index to allied health literature, and the Chinese database Sino-Med were searched on March 31, 2020, for studies on PAE for PPH. The data for PAE indication, agents, arteries, success rate, complications, and outcomes were extracted and syncretized for meta-analysis. Results From 1075 identified articles, 113 abstracts or full articles were retrieved and 43 studies were finally identified as meeting the including criteria. The results demonstrated that the indications for PAE were as follows: uterine atony, placental abnormality, delivery tract injury, disseminated intravascular coagulation, arteriovenous malformation, and vaginal hematoma. The embolization agents mostly in order were gelatin sponge particles, polyvinyl alcohol particles, Gelfoam, N-butyl cyanoacrylate, microcoil, and glue; for arteries, they were mostly uterine artery and internal iliac artery. The clinical success rate was 90.5%, whereas the technical success rate was 99.3%. The most common complications of PAE were postembolization syndrome and menstrual abnormality. Conclusions and Relevance The emergent PAE is a safe and effective method with high success rate in life-threatening PPH management. Gelatin sponge granules measuring 500 to 1000 μm in diameter have safe results. Pelvic arterial embolization may affect the recovery of menses and increase PPH in the subsequent pregnancy, but there was no noted correlation with fetal growth restriction. Target Audience Obstetricians and gynecologist, family physicians Learning Objectives After participating in this activity, physicians should be better able to explain the causes of PPH; identify which arteries should be chosen for embolization; and describe the advantages of PAE for PPH management.

Background: Around the world, one woman every minute dies as a result of postpartum hemorrhage (PPH) and it remains the single major cause of maternal mortality and morbidity. The early identification of risk factors and effective prevention and management of PPH are critical to minimize the impact of PPH. Carbetocin, a new drug for the prevention of uterine atony, is a synthetic analogue of oxytocin with a half-life of up to 4 to 10 times longer than that of oxytocin. In comparison with oxytocin, it is used as a single-dose injection instead of an infusion and can be given intravenously or intramuscularly. Objective: To evaluate the effect of carbetocin in preventing postpartum hemorrhage after vaginal delivery in comparison with combined oxytocin and methergine. Patients and methods: This study was conducted at Al-Galaa Maternity Hospital during the period from 1 June to 1 December 2020. The study included 100 candidates between 37 to 40 weeks with a risk factor to develop PPH divided randomly into two equal groups: Group A received a single 100 mg IM dose of carbetocin (Pabal®) and Group B received 5 IU IM oxytocin (Syntocinon®) combined with 1 mL, 0.2 mg IM methylergonovine maleate (Methergine®). Results: Carbetocin was more effective, with significant difference, in reducing the time of 3rd stage of labor, reducing amount of blood loss and drop of both HB% and hematocrit levels with significant decreased incidence of side effects. Conclusion: A single 100 mg IM dose of carbetocin (Pabal®) may be more effective as compared to 5 IU IM oxytocin (Syntocinon®) combined with 1 mL, 0.2 mg IM methylergonovine maleate (Methergine®) in reducing postpartum blood loss with a smaller drop in hemoglobin levels.

Preeclampsia and eclampsia are hypertensive disorders of pregnancy associated with abnormal placental vascular development. The systemic angiogenic imbalance, endothelial dysfunction and proinflammatory state caused by abnormal placental development results in abnormalities in renal, hepatic, pulmonary and neurologic function. Neurosensory symptoms related to pregnancy induced hypertension (PIH), the most devastating of which are intracranial hemorrhage and seizure, are among the leading causes of maternal and perinatal morbidity and mortality globally, yet risk stratification strategies and targeted therapies remain elusive. Current treatment for preeclampsia with severe features is limited to delivery, antihypertensive therapy, and magnesium sulfate seizure prophylaxis. Magnesium sulfate reduces seizure rates among severe preeclamptics, but predisposes patients to weakness, uterine atony, pulmonary edema and respiratory depression. Therefore, this drug should ideally be administered only to the subset of preeclamptics who are at increased risk for neurologic complications. While there are no objective methods validated to predict eclampsia, we hypothesize that measurement of optic nerve sheath diameters, optic disc height and middle cerebral artery transcranial doppler resistance indices may be useful in identifying subclinical cerebral edema, potentially allowing us to recognize those patients at highest risk for seizures. This summary of the current literature provides an initial framework for developing more sophisticated and noninvasive methods for identifying, monitoring and treating parturients who are at highest risk for neurologic complications from preeclampsia.

Objective To minimize the adverse events of uterine compression suture in controlling postpartum hemorrhage (PPH) and to search for a prophylactic approach to potential PPH. Methods A retrospective analysis was performed in 39 women with removable retropubic uterine compression suture (RRUCS) to stop PPH due to uterine atony during cesarean section (CS). The procedure was to suspend and compress the uterus to the retropubic abdominal wall using an absorbable suture. Results The technique was sufficient to stanch bleeding immediately in 36 patients (92.31%, 36/39). No morbidity or abnormalities occurred in women who underwent RRUCS. Subsequent pregnancies occurred in 10 cases, but the others lacked the desire for future pregnancy. Conclusion RRUCS is a simple, safe, and effective technique in controlling atonic PPH; it is also used as a prophylactic application in patients with potential PPH after CS.

A wide range of fetal interventions are being performed worldwide to save the fetus's life, prevent permanent fetal organ damage, and allow a successful transition to extrauterine life. However, these are invasive procedures and can be associated with serious complications. This article focuses on promoting a culture of safety by highlighting five common error traps while anesthetizing patients for fetal interventions. They include failure to preserve uteroplacental perfusion and gas exchange, failure to achieve adequate uterine relaxation prior to hysterotomy, failure to monitor the fetus and prepare for fetal/neonatal resuscitation, failure to prepare for maternal hemorrhage, and failure to promptly treat uterine atony. Practical tips for avoiding these serious complications will also be discussed.

The Maternal Mortality Rate (MMR) in Indonesia is around 90% at the time of delivery. in Indonesia until 2018 the Maternal Mortality Rate is still high at 305 per 1000 live births[1]. This is caused by postpartum bleeding due to several factors such as uterine atony and perineal rupture. The research objective was to determine the relationship between birth weight of infants and perineal rupture in Primipara at Japara Public Health Center, Kuningan Regency in 2019. The research method was analytic with a cross sectional approach, sampling with a total sampling technique with a total of 52 mothers giving birth. The instrument used was a checklist sheet and the analysis used Spearman Rank. Based on the results of the univariate analysis study, most mothers gave birth to babies with normal birth weight, namely around 59.6%, while most of the mothers experienced perineal rupture, namely around 51.9%. The results of the bivariate analysis showed a value (p = 0.09), this indicated that there was a significant relationship between birth weight of infants and perineal rupture in mothers who gave birth. It was concluded that there was a significant relationship between birth weight of infants and perineal rupture in mothers who gave birth. It is hoped that midwives will always carry out labor management in accordance with the standards of normal delivery care when giving birth and teach pregnant women how to massage the perineum.

espanolLa hemorragia postparto (HPP) es considerada una emergencia obstetrica y es una de las cinco principales causas de mortalidad materna a nivel mundial y la causa principal de mortalidad materna en paises de ingresos bajos. La hemorragia posparto es la segunda causa mas importante de muerte materna en Ecuador. Por lo anterior se plantea realizar un compendio de las causas de Hemorragias Maternas y asi brindar una actualizacion del tema disponible para el campo medico en general, bajo la premisa de que esta complicacion obstetrica no se le ha otorgado la importancia necesaria para entenderla como una real emergencia medica. Considerando las herramientas de busqueda tecnologicas disponibles se ha de encontrar las publicaciones cientificas que nos permita abordar, de manera actualizada, las causas de la Hemorragia postparto. En la revision bibliografica realizada hemos encontrado, principalmente que la muerte es completamente evitable si hay un diagnostico oportuno y una estimacion sincera de que las HPP son una emergencia para tratarse como tal. Por ultimo pero no menos importante, esta complicacion femenina no dispone de datos estadisticos vigentes. Un estudio senala como causas mas frecuentes: la atonia uterina, los traumas/laceraciones, la retencion de retos placentarios post concepcion y las alteraciones de la coagulacion. Algunos autores consideran a la atonia uterina como la causa mas frecuente; responsable del 50 al 70% de las hemorragias post alumbramiento y del 4% de todas las muertes maternas. Tambien, el desgarro del suelo pelvico es una causa a tomar en consideracion, ya que el mismo va acompanado de una denervacion de la musculatura del suelo pelvico por dano en los nervios pudendos y sacros, a consecuencia de partos vaginales, la cual pudo deberse a la instrumentacion empleada en la atencion del parto. EnglishPostpartum hemorrhage (PPH) is considered an obstetric emergency and is one of the top five causes of maternal mortality worldwide and the leading cause of maternal mortality in low-income countries. Postpartum hemorrhage is the second leading cause of maternal death in Ecuador. Therefore, it is proposed to make a compendium of the causes of Maternal Hemorrhages and thus provide an update on the subject available for the medical field in general, under the premise that this obstetric complication has not been given the necessary importance to understand it as a real one. medical emergency. Considering the available technological search tools, it is necessary to find the scientific publications that will allow us to address, in an updated way, the causes of Postpartum Hemorrhage. In the bibliographic review of death we have found, mainly that death is completely avoidable if there is a timely diagnosis and an estimate since PPH is an emergency to be treated as such. Last but not least, this female complication does not have current statistical data. A study indicates the most frequent causes: uterine atony, trauma / laceration, retention of post-conception placental challenges and coagulation disorders. Some authors consider uterine atony as the most frequent cause; responsible for 50 to 70% of postpartum hemorrhages and 4% of all maternal deaths. Also, the tear of the pelvic floor is a cause to take into consideration, since it is accompanied by a denervation of the pelvic floor muscles due to damage to the pudendal and sacral nerves, as a result of vaginal births, which could be due to the instrumentation used in delivery care.

Background. Intrauterine balloon tamponade (IUBT) and compression sutures have been widely used in recent years in the management of postpartum hemorrhage (PPH). However, there is scant literature directly comparing the clinical scenarios that led to the discriminant selection of these management modalities and the direct clinical outcomes. The purpose of this study is to compare the patient characteristics and clinical risk factors that led to the use of IUBT and compression sutures in the management of major PPH as well as the immediate outcome in a retrospective cohort. Methods. Patients who had IUBT or compression sutures applied due to major PPH (>1000 ml) from 2014 to 2018 in a single obstetric unit were recruited. The patient characteristics and clinical outcome of the two groups were compared. Results. A total of 67 patients had IUBT and 29 patients had compression sutures applied as the first uterine sparing technique. Apart from more vaginal deliveries (25.4% vs. 3.5%) in the IUBT group compared to compression sutures, there were no significant differences between the two groups in terms of patient characteristics. The IUBT group had a slightly higher blood loss at the start of the uterine sparing procedure (239 ml, p = 0.049 ) and received more transfusions, despite no differences in the total blood loss, hemogloblin level, incidence of coagulopathy, and intensive care unit admission between the two groups. There was no significant difference in the overall success rate between IUBT and compression sutures to control PPH without additional surgical intervention or hysterectomy (73.1% vs. 55.1%, p = 0.15 ) or the success rate for PPH due to uterine atony (32.8% vs. 20.7%), though IUBT apparently performed better than compression sutures in cases of placenta praevia (77.3% vs. 16.7%, p = 0.01 ). Blood loss > 1.5 l at the start of the procedure, presence of placenta accreta, and presence of coagulopathy were found to be significant poor prognostic factors for both procedures to control PPH. Conclusions. There were no dominating patient characteristics that favoured the selection of either IUBT or compression sutures in the management of severe PPH except for the mode of delivery. Both procedures had equally high overall success rates to control PPH, but IUBT performed better in placenta praevia cases as compared to compression sutures.

Objective To identify changing trends in peripartum hysterectomy (PH), both elective. cesarean hysterectomy and emergency cesarean hysterectomy, at a single training and research hospital over the last 17 years in Istanbul, Turkey. Materials and methods A retrospective cohort study was performed between January 2001 and September 2017. The records of all patients who had PH at Kanuni Sultan Suleyman Training and Research Hospital were analyzed. Results There were 243 cases of PH during the study period. A total of 266,386 births occurred, of which 60.1% were vaginal deliveries and 39.8% were cesarean sections. The incidence of PH increased from 0.67 per 1000 deliveries to 1.14 per 1000 deliveries during 2001–2008 and 2009–2017, respectively, with an overall incidence of 0.91 per 1000 deliveries during the 17 years. The main indication for PH changed significantly during this time from uterine atony (57.1%) to placenta accreta spectrum (85%). About 37% of women who underwent PH had at least one previous cesarean delivery during 2001–2008, whereas that percentage increased to 95.4% during 2009–2017. Conclusion Placenta accreta spectrum was the leading cause of PH and was associated with significant maternal morbidity and mortality.

Background: Postpartum haemorrhage is the leading cause of maternal deaths worldwide, the majority of which occur in low resource settings. Uterine atony is the commonest cause of postpartum haemorrhage. Uterine balloon tamponade (UBT) is an effective method of treating refractory postpartum haemorrhage. Aim: Commercial UBT devices are often not affordable and not readily available in rural settings. The aim of this paper is to report on three cases of postpartum haemorrhage successfully managed with uterine balloon tamponade using Foley catheters. Case Reports: We report on three patients with major obstetric haemorrhage from uterine atony who were successfully managed with uterine balloon tamponade using Foley’s urethral catheter. The first two patients had primary postpartum haemorrhage while the third patient had significant bleeding during the surgical evacuation of the uterus for a molar pregnancy. In each case, uterine bleeding was refractory to pharmacologic uterotonics. They all had uterine tamponade with a Foley catheter with the dramatic resolution of their bleeding. Conclusion: In well-selected patients, uterine balloon tamponade with Foley catheter is cheap, arrests bleeding and prevents clinical deterioration among women with refractory postpartum haemorrhage, especially in low resource settings where commercial balloon tamponade may not be available or affordable.

Uterine atony is a serious obstetrical complication since it is the leading cause of postpartum hemorrhage. Postpartum hemorrhage (PPH) is one of the 5 major causes of postpartum mortality; therefore, it requires immediate medical intervention, independent of whether delivery occurs normally or with a cesarean section. While in the past years most cases of postpartum hemorrhage were caused due to uterine atony following vaginal delivery, in recent years most PPH cases indicate a significant association with cesarean delivery. There are several methods used in order to avoid such a life-threatening complication, ranging from risk assessment to prevention, and finally medical intervention and management, if such an event occurs. In this scientific paper emphasis is given on the so-called "uterotonic" agents that are currently used, including oxytocin among others. It is, therefore, important to be familiar with these agents as well as understand the physiological mechanism by which they work, since they are used in everyday practice, not only for managing but also for preventing PPH. There are several potential questions that arise from the use of such "uterotonic" agents, and most specifically of oxytocin. Maybe one of the most important issues is the determination of optimal dosing of oxytocin in order to avoid PPH after a cesarean section.

Maternal death from haemorrhage is decreasing: in the last 15 years the number of deaths has been halved. This improvement demonstrates the progress made in hemorrhage management as a result of collective efforts. The number of deaths in this triennium is 22, representing 8.4% of maternal deaths and a maternal mortality ratio by haemorrhage of 1.0/100,000 live births. Nevertheless, there is a worrying proportion of deaths from occult haemorrhage. These occult haemorrhages most often occurred after caesarean sections. A lack of surveillance in the immediate follow-up was generally associated. One or more factors of sub-optimal care were present in 84% of the cases, and 88.9% of deaths were considered possibly or probably preventable. Delay in the diagnosis of haemorrhage, delay in surgical treatment, an insufficient transfusion strategy and inappropriate locations of care were the most frequently reported factors. The experts suggest that risk factors for haemorrhage should be identified in order to propose the most appropriate facility for childbirth. They encourage the strategies for early diagnosis of haemorrhage (attentive and regular monitoring, rapid haemoglobin measurement, abdominal ultrasound) and surgical intervention in case of hemoperitoneum.

Background: Postpartum haemorrhage is one of the leading causes of maternal morbidity and mortality worldwide. It occurs predominantly in developing countries due to poorly developed infrastructures and lack of skilled birth attendants. Objective: To identify the prevalence, causes and risk factors of primary postpartum haemorrhage following vaginal deliveries in a referral hospital (Douala General Hospital-Cameroon). Methods: This was a descriptive and analytical study carried in the Douala General Hospital (DGH) for which socio-demographic, clinical, obstetric and post-partum data were collected using a pre-tested questionnaire. Descriptive statistics, multivariate analysis and logistic regression allowed us to present and discuss our results, with a 95% confidence interval (CI) and p value 0.05. Results: The prevalence of Primary Postpartum Haemorrhage was 1.33%. Quantification of bleeding was reported in only 13.15% of cases. The main causes were: uterine atony (36.18%), placental retention (25.65%), cervical tears (12.50%), perineal tears (10.52%) and cervico-vaginal tears (08.52%). The risk factors were: age between 19 - 35 years aOR = 4.52; 95% CI = 2.65 - 7.98; p = 0.021); unemployment (aOR = 4.74; 95% CI = 2.91 - 6.02; p = 0.001); being multigravida (aOR = 9.21; 95% CI = 6.43 - 12.48; p = 0.035); history of abortion (aOR = 5.11; 95% CI = 2.05 - 7.29; p = 0.004); preterm delivery (aOR = 6.88; 95% CI = 2.72 - 9.06; p = 0.002); duration of labour > 12 hours (aOR = 4.05; 95% CI = 2.46 - 7.98; p = 0.003) and macrosomia (aOR = 3.27; 95% CI = 1.03 - 5.68; p = 0.041). Conclusion: Primary postpartum haemorrhage remains a poorly assessed obstetric complication in the maternity ward of the Douala General Hospital (DGH); Training staff on quantifying postpartum blood loss and monitoring the second and third stages of labour can help to better manage and reduce its occurrence.

In our medical practice, in particular obstetrics, it is difficult to change certain consolidated dogmas, but the necessity and the current situation of our obstetrical exercise pushed us to find new technical supports, to make the exercise of our specialty as stripped of pitfalls as possible. Our work is summarized in a prospective comparative study, aimed at evaluating the existence or not of a difference between the administration of oxytocin just before the hysterotomy in a cesarean section and its administration after fetal extraction. We used a set of criteria to include patients in our study. This study took place over a period of one year (2020) in the Mother and Child regional center, in Meknes Imperial city, Morocco, involving a total number of 364 patients. With a group A comprising 176 patients 48% (176/364) who received oxytocin just before the hysterotomy and a group B of 188 patients 52% (188/364) who received it classically after fetal extraction. The difference was very significant as detailed in the article. Conclusion: the very convincing results of our study and the difference between the two groups, allowed us to demonstrate the effectiveness of our process and to endorse its use in our routine practice, with the perspective of conducting a prospective randomized study on a larger series.

Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality in developing countries. Objective: To determine the maternal outcome by an audit of one year among the cases of primary postpartum hemorrhage at a tertiary care hospital. Methodology: This cross-sectional study was conducted in the Department of Obstetrics and Gynecology, DHQ Teaching Rawalpindi from 1st January 2019 to 31st December 2019. A total of 9122 deliveries were conducted at the hospital. We reviewed the charts of all the patients who fulfilled our inclusion criteria and gathered data on a structured, pre-tested proformas prepared for the purpose. Results: A total of 9122 maternities were reported during the study period with the frequency of PPH 70 (0.77%). Booking status, 25 (35.7%), high parity 18 (25.7%), and uterine atony in 54 (77%) out of 70 PPH patients, were associated with PPH. Medical management of PPH with uterotonic drugs was successful in 23 (30%) of patients. Uterine packing was done in 27 (38%) patients and bleeding was successfully arrested in 24 (90%) of these 27 patients. Hysterectomy was performed in 9 (12.8%) patients. Maternal death due to PPH was reported in 1 (1.4%) cases. Conclusion: PPH is the leading cause of maternal mortality and morbidity, associated with booking status, parity, and uterine atony. Hospital management should emphasize the predefined protocol to be followed in managing a patient with postpartum hemorrhage. "This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."

Introduction: Postpartum haemorrhage is a significant contributor to maternal morbidity & mortality Obstetric hemorrhage accounts for 38% of maternal deaths, of which PPH accounts for 25%. Objective: The present study was undertaken to study maternal morbidity and mortality in cases of PPH. Materials and Methods: This was a retrospective study conducted in department of Obstetrics & Gynaecology, S.R.T.R.G.M.C. Ambajogai from June 2015 to march 2017 on sample size of 168 patients. Results: The records were analyzed with respect to maternal age, parity, socio-demographic & etiological profile and maternal consequences in cases of PPH at our tertiary care centre. In present study incidence of PPH came out to be 29% due to inclusion of all booked and referred cases. Main cause of PPH in this study was uterine atony i.e. 69%. Second common cause was traumatic i.e. 20%. Incidence of peripartum hysterectomy done for atonic cases was 12.06% and 5.88% in cases of rupture uterus. 82.14% cases were given blood transfusion. Maternal death due to haemorrhage in our study was 5.3%. Conclusion: Proper anticipation and skilled management, along with timely referral of PPH cases will lead to significant reduction in maternal morbidity & mortality, as PPH is a significant contributor to maternal mortality. Maternal deaths due to PPH are clearly declining that is due to improved socioeconomic status, high standard medical and surgical management, use of NASG and expert care delivered at our institute. Keywords: Postpartum haemorrhage, Maternal morbidity and mortality, Peripartum hysterectomy, Disseminated intravascular coagulation.

Postpartum hemorrhage (PPH) is the leading cause of global maternal mortality and accounts for approximately one-quarter of all maternal deaths worldwide. Prevention of excess maternal deaths requires a coordinated approach to prevention, early recognition, and intervention by a multidisciplinary team. Although some women have risk factors for PPH that can be identified during pregnancy or during labor or birth, most women with severe PPH do not have any risk factors. Therefore, all pregnant women must be considered to be at risk of PPH. Common causes include uterine atony, retained placenta, trauma to the genital tract or uterus, and coagulopathy. The pivotal role of fibrinogen and hyperfibrinolysis in the evolution and as a treatment target for PPH is increasingly recognized. Coagulopathy can be an early feature in PPH that may be unrecognized, as it can be present before massive transfusion has occurred. Identification of coagulopathy by viscoelastic point-of-care testing or conventional laboratory assays can be helpful in guiding management of PPH and preventing severe maternal outcomes.

Purpose Oxytocin is the first-line agent to prevent and treat uterine atony during cesarean delivery (CD). We compared the effective dose in 50% of the parturients (ED50) of a prophylactic oxytocin bolus during CD in young (

O bjective - The study aimed to investigate the characteristics of women and their children as well as the deliveries completed us- ing forceps in one tertiary center. M aterial and Methods - The study included all women who had vaginal delivery during 2019. Women were classified according to use of the outlet forceps for delivery into the study and control group. We recorded maternal age and parity, duration of delivery, stimulation and epidural analgesia use, neonatal measures and Apgar score, maternal and neonatal complications after delivery. R esults - Of the 3,570 vaginal births, forceps was applied 23 (0.64%) times. Most women were aged

Background. Despite the availability of comprehensive emergency obstetric care at Dodoma Regional Referral Hospital, deaths due to obstetric haemorrhage are still high. This study was carried out to analyse the circumstances that had caused these deaths. Methods. A retrospective review of all files of women who had died of obstetric haemorrhage from January 2018 to December 2019 was made. Results. A total of 18,296 women gave birth at DRRH; out of these, 61 died of pregnancy-related complications of the deceased while 23 (38%) died of haemorrhage, with many of them 10 (44%) between the age of 30 and 34. Many were grand multiparous women 8 (35%) and almost half of them (11 (48%)) had stayed at DRRH for less than 24 hours. More than half (12 (52%)) had delivered by caesarean section followed by laparotomy due to ruptured uterus (8 (35%)). The leading contributing factors to the deaths of these women were late referral (6 (26%)), delays in managing postpartum haemorrhage due to uterine atony (4 (17%)), inadequate preparations in patients with the possibility of developing PPH (4 (17%)), and delay in performing caesarean section (3 (13%)). Conclusion. Maternal mortality due to obstetric haemorrhage is high at Dodoma Regional Referral Hospital where more than one-third of women died between 2018 and 2019. Almost all of these deaths were avoidable. The leading contributing factors were late referral from other health facilities, inadequate skills in managing PPH due to uterine atony, delays in performing caesarean section at DRRH, and inadequate preparation for managing PPH in patients with abruptio placentae and IUFD which are risk factors for the condition. There is a need of conducting supportive supervision, mentorship, and other modes of teaching programmes on the management of obstetric haemorrhage to health care workers of referring facilities as well as those at DRRH. Monitoring of labour by using partograph and identifying pregnant women at risk should also be emphasized in order to avoid uterine rupture.

Background: Both oxytocin and carbetocin are used to prevent uterine atony and post-partum haemorrhage after caesarean delivery in many countries, including Norway. Oxytocin causes dose-dependent ST-depression, troponin release, prolongation of QT-time and arrythmia, but little is known about myocardial effects of carbetocin. We have previously demonstrated comparable vasodilatory effects of oxytocin and carbetocin and are now undertaking a Phase 4 trial to investigate whether carbetocin causes similar changes to myocardial markers compared with oxytocin. Methods: Our randomized controlled trial will be conducted at three obstetrics units at Oslo University Hospital and Akershus University Hospital, Norway. Planned enrolment will be of 240 healthy, singleton pregnant women aged 18 to 50 years undergoing planned caesarean delivery. Based on pilot study data, each participant will receive a one-minute intravenous injection of either oxytocin 2.5 IU or carbetocin 100 µg during caesarean delivery. The prespecified primary outcome is the change from baseline in high-sensitive troponin I plasma concentrations at 6–10 hours after study drug administration. Secondary outcomes include uterine tone grade at 2.5 and five minutes after study drug administration, adverse events for up to 48 hours after study drug administration, estimated blood loss within eight hours of delivery, need for rescue treatment and direct/indirect costs. Enrolment and primary analysis are expected to be completed by the end of 2021. Discussion: Women undergoing caesarean delivery should be assessed for cardiovascular risk particularly as women with an obstetric history of pregnancy induced hypertension, gestational diabetes mellitus, preterm birth, placental abruption, and stillbirth are at increased risk of future cardiovascular disease. Any additional ischaemic myocardial risk from uterotonic agents will need to be balanced with the benefit of reducing the risk of postpartum haemorrhage. Any potential cardiotoxicity difference between oxytocin and carbetocin will help inform treatment decisions for pregnant women. Registration: Clinicaltrials.gov NCT03899961 (02/04/2019).

Objective To analyze all the variables in women who received fibrinogen for postpartum hemorrhage (PPH) using hierarchical cluster analysis, to provide greater insight into the risk variables involved in these women. Methods This retrospective study of women with at least 500 mL of bleeding at birth or during the postpartum period and treated with fibrinogen was conducted at the Department of Obstetrics and Gynecology, Ataturk University School of Medicine from January 2013 to January 2018. Data on the women were obtained from medical records and various risk variables were recorded and analyzed using hierarchical cluster analysis. Results A total of 114 women with PPH were included in the study. Based on a dendrogram, three main clusters of similar quality variables were created: 1) gravida, parity, age, cervical/vaginal hematoma, laparotomy, hypogastric artery ligation, uterine artery embolization, uterine artery ligation, uterine atony, distance from outer center, lowest hemoglobin, preoperative platelets, endometritis, preoperative white blood cells; 2) lowest fibrinogen, highest fibrinogen, type of birth, placenta invasion anomaly, Bakri balloon tamponade, postpartum hysterectomy, preoperative activated partial thromboplastin time (APTT), preoperative international normalized ratio (INR), placental abruption, in-utero ex fetus; 3) postoperative APTT, postoperative INR, maternal mortality, erythrocyte transfusion, plasma transfusion, hospital stay time, disseminated intravascular coagulation/HELLP syndrome, highest hemoglobin, blood group, postoperative platelets, platelet transfusion, pre-eclampsia/eclampsia, fibrinogen extract. Conclusion According to the cluster analysis, we should keep fibrinogen extract in the foreground especially in the treatment of hemorrhage in patients with variable conditions. As a result, we can determine whether fibrinogen extract, which has a high economic cost, should be kept at each center. We can also direct which patient will be referred in accordance with the referral steps.

Aim: If the initial treatment techniques fail, intrauterine balloon tamponade (IUBT) devices such as Bakri balloon tamponade (BBT) is an effective treatment for reducing the bleeding in uterine atony patients. However, the duration of the Bakri balloon varies widely in clinical practice, and there is no consensus in this issue. This study aimed to compare the clinical outcomes of the Bakri balloon removed in less or more than 12 hours in patients with severe postpartum haemorrhage (PPH). Materials and methods: This retrospective study included 108 patients who underwent Bakri balloon for severe PPH after vaginal delivery. Patients were divided into two groups as the duration of Bakri balloon 8-12 hours (Group I) and >12 hours (Group II). BBT was considered to be successful if the bleeding was stopped, and the patient did not require additional invasive procedures. Age, parity, gestational week, cause of bleeding, presence of co-morbidity that may increase bleeding (multiple gestation, magnesium sulphate infusion), estimated blood loss (EBL) before and after Bakri balloon, postpartum infection, erythrocyte and fresh frozen plasma requirement and invasive procedure requirement of the groups were compared. Results: In group I, 26 patients (52%) underwent erythrocyte transfusion, and 18 patients (36%) underwent both erythrocyte and fresh frozen plasma (FFP) transfusion. In group II, 28 patients (41.2%) underwent erythrocyte transfusion, and 21 patients (30.9%) underwent both erythrocyte and FFP transfusion. These differences were not statistically significant (p=0.42 and p=0.21, respectively). Bacri balloon was failed to reduce bleeding in one patient (2%) in group I and one patient (1.5%) in group II, and these patients had to undergo invasive surgical procedures (hysterectomy). There was no statistically significant difference between the groups in terms of failed to reduce bleeding rates (p=0.52). Conclusion: Keeping the Bakri balloon in place for longer than 12 hours does not provide favourable clinical outcomes compared to keeping in place for less than 12 hours.

Absztrakt: A Nemzeti Véradó és Vérmentő Program célja a vérkészítmények észszerű és indokolt alkalmazásának támogatása és az irracionális transzfúziós gyakorlat megszüntetése, ezáltal a betegbiztonság növelése. Az általános elvek mellett a programnak vannak speciális szülészeti vonatkozásai is. A szülészeti, különösen a postpartum vérzések ugyanis világszerte az anyai halálozás vezető okai közé tartoznak, előfordulásuk pedig a fejlett országokban emelkedő tendenciát mutat. A szülésre való felkészülés fontos elemei a vérkép rendezése, a rutinszerű profilaktikus vagy terápiás vaspótlás és a szülészeti vérzés tekintetében nagy rizikóval rendelkező gravidák időben történő kiszűrése, gondozása. A peripartum vérzések legfőbb okai az abruptio placentae, placenta praevia, uterusatonia, szövetretenció a méh üregében, sérülés, a haemostasisrendszer zavarai és ezek kombinációi. A postpartum vérzés megelőzése érdekében a szülés során fontos a lepényi szak aktív vezetése, melynek alapvető eleme az uterotonikumok profilaktikus alkalmazása. A vérmentő technikák használata – megfelelő indikációval – császármetszés és postpartum vérzés során is megfontolandó. A szülészeti vérzések kezelése során a legfőbb prioritás a lumenes, sebészi vérzés szülész által történő ellátása. A masszív vérzéshez társuló szekunder coagulopathia megszüntetése érdekében a faktorkoncentrátum-alapú, viszkoelasztikus teszttel monitorozott, egyénre szabott kezelési mód preferált, de ilyenkor a terhesség során érvényes – és a nem terhes állapottól eltérő – referencia- és célértékeket kell alkalmaznunk. A szülészeti vérzések részben a megelőzhető halálokok közé tartoznak. A Nemzeti Véradó és Vérmentő Program szülészeti alkalmazásával reményeink szerint tovább javíthatók a szülészeti vérzésekből származó morbiditási és mortalitásai adatok. Orv Hetil. 2020; 161(37): 1588–1598.

Aim: This study aimed to compare the use of misoprostol to carbetocin in reducing blood loss during cesarean section in low risk patients.Materials and Methods: This randomized controlled study enrolled 300 patients who were eligible. 150 women received carbetocin100ug i.v intra-operative immediately after extraction of the fetus during cesarean section (group A). They were compared to 150 women who received misoprostol 600ug rectally immediately before sterilization during caesarean section (group B).Results: There is significant difference in intraoperative uterine atony [3 (2.0%) vs 11 (7.3%) P 0.018] and surgical hemostatic measures as uterine artery ligation and uterine compression sutures [0.00 vs 3.00 (2%) P < 0.00 and 0.00 vs 12.00 (8%) P < 0.00] were higher in misopristol group. Also, the need for other uterotonic drugs was significantly higher in misopristol group (10.0 ± 0.0 vs 13.15 ± 5.28, P < 0.001 and the difference in hemoglobin and hematocrit values before and after delivery were slightly higher in misopristol group with no statistical significance (10.71 ± 0.98 vs 10.86 ± 0.84, P < 0.15 and 33.86 ± 2.8 vs 34.29 ± 2.7, P < 0.17).Conclusion: Intravenous therapy infusion of 100 ug carbetocin reduced but no significantly blood loss during cesarean section than 600ug rectal misoprostol.

Background Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide, with uterine atony responsible in 80% of cases. In intractable cases, hysterectomy is the final treatment, but it has complications. Many doctors in developing countries with high maternal mortality rates from postpartum hemorrhage can perform cesarean deliveries but cannot perform hysterectomy. Patients with postpartum hemorrhage who need hysterectomy in these countries will die in such cases, whereas, if doctors know this simple, easily learned technique, such patients may survive. Technique Esike's technique is a uterine-compression method that uses supplies generally available at delivery hospitals. Six sutures are placed in the lower uterine segment, three anteriorly and three posteriorly. Starting with the middle sutures, the sutures are tied at the fundus with the help of an assistant to provide uterine compression. The more laterally placed sutures are then tied similarly, resulting in uterine compression and stoppage of postpartum hemorrhage. Experience Esike's technique was used in controlling life-threatening, uncontrollable postpartum hemorrhage in 18 women and was successful in 16 (89%) without requiring hysterectomy. Conclusion Esike's technique is effective in controlling life-threatening postpartum hemorrhage and can be used in low-resource settings with commonly available supplies and performed by doctors with a common level of training.

A 35-year-old primigravid woman with chronic idiopathic intestinal pseudo-obstruction presented to our institution. Except for an enlarged fetal bladder, her pregnancy was almost uneventful until she developed pre-eclampsia requiring emergent cesarean section at 34 weeks gestation. After delivery, intractable uterine atony developed with blood loss reaching 3500 mL within 15 min. Following a B-Lynch suture, the bleeding attenuated but uterine atony persisted; lochia persisted for 3 months post-partum. The infant was diagnosed with megacystis microcolon intestinal hypoperistalsis syndrome after birth. The mother's clinical course and previous reports suggested that atonic bleeding was associated with the pathology of chronic idiopathic intestinal pseudo-obstruction; the infant's disease was considered to be maternal-related disease. Clinicians should be vigilant in pregnant patients with chronic idiopathic intestinal pseudo-obstruction especially with these complications.

Postpartum hemorrhage is the leading cause of maternal death worldwide with 5 – 10% of incidence. The etiology of postpartum hemorrhage are uterine atony, retensio placentae, genital tract laceration, retained placental tissue and coagulation disorders. It was estimated 2 hours period from the onset of postpartum hemorrhage toward the maternal death, meanwhile it was 12 hours in antepartum hemorrhage. It is therefor early diagnosis and prompt management is essential. The solid and skilled teamwork is needed in order to successfully manage postpartum hemorrhage and to avoid maternal death.

Objective:Finding the real effect of cesarean section in the second stage of labour Study Design: Observational prospective study. Study Settings: Al Karkh Maternity Hospital/Baghdad/Iraq the period between April, 2018 and April, 2019.Patients & Method: A total of 333 term pregnant women in established labour and who had a primary emergency cesarean section either in the first stage or second stage of labor. Demographic characteristics were collected for all participants. A comparison of the outcomes of the two groups was done, it included a maternal outcome, composed of the following: intraoperative surgical complication, blood transfusion, endometritis, or wound complication and a neonatal outcome, which included the following: Apgar score at 5 minutes, weight, intubation in the absence of meconium, neonatal intensive care unit admission, fetal injury or neonatal death.Results: Patients who had a cesarean delivery in the second stage of labour in our study were found to be older, multiparous and had a higher BMI at presentation. Teenagers were more likely to have cesarean section in first stage (12.5% vs. 3% in second stage). Second stage cesarean sections were associated with higher risk of uterine atony (RR 6.28 with 95% CI 4.16-9.4), incisional extensions (RR 19.1 with 95% CI 8.9-40.9), accidental bladder injuries (RR 32.6 with 95% CI 4.2-251), hematomas (RR 4.1 with 95% CI 1.9-8.7), postoperative endometritis (RR 3.08 with 95% CI 1.4-6.3), and required longer time to deliver the baby (5.1 vs. 3.8 minutes p value 0.0001). They were associated with delivery of higher birth weight infants (mean 3.63 kg vs. 3.1kg p value 0.0001). No difference found regarding the 5 minutes APGAR score, fetal injury, nor infant INCU admission between the two groups.Conclusion: Cesarean delivery in the second stage of labour carries high risk of complications in our settings, both intra-operative surgical complications and short-term wound complications were higher than for cesarean delivery in the first stage of labour, and significant enough to warrant seeking for a proper intervention.

Planned caesarean delivery (CD) did not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity in twin pregnancy between 32 0/7 and 38 6/7 weeks of gestation, with the first twin in the vertex presentation. As prevalence rises for the second twin, emergency CD is necessary for delivery of the second twin after vaginal delivery of the first twin. Waiting after 38 weeks' gestation essentially requires close fetal and maternal surveillance to identify if those pregnancies may benefit to extend a gestational period. It is important to construct a system in which an emergency CD can be performed anytime. The caesarean section does not change in even multifetal pregnancy. Each step after laparotomy has few tips: (1) because the uterus strongly leans to the right, image the uterine rotation. To avoid thick vessels on the uterine lateral wall, perform long U-shaped incision using a scissor. 2) Ensure not to rupture the membrane of the second twin before delivery of the first twin. (3) Check the presentation of the second twin before rupture of that fetus's membrane. The second twin tends to change the presentation. If the upper uterine segment will clamp down and entrap the second twin, a vertical uterine incision is performed without hesitation. Women with multifetal pregnancy are at increased risk of postpartum hemorrhage (PPH). Mainly PPH is caused by uterine atony. Oxytocin should be prepared before starting the CD. All bleeding may not be recognized in the operation field. Do not lose the timing of blood transfusion.

Background: Postpartum haemorrhage (PPH) is one of the leading causes of maternal mortality and morbidity especially in the developing countries like India. Uterine compression sutures, originally described by B-Lynch et al can successfully control life-threatening PPH.With this background, we studied the use of modified B-Lynch sutures in our setup. Materials and Methods: It was a single centre, hospital based cross sectional study conducted in the department of obstetrics and gynaecology in a tertiary care hospital in Maharashtra. About 50 cases during the study period (Nov 2017 to June 2019) who failed the medical management of control of PPH were included in the study. Demographic details like age, gestational age, religion, socio economic status and gravid were noted in the case record form. Amount of blood loss, success rates, immediate complications and follow up fertility were assessed. Results: Among the 50 study subjects, 24% had blood loss of 1500ml, 16% had loss of 1501 to 2000ml and 6% had loss more than 2000ml in the present study. About 80% of the cases were successful and 20% failed in the present study. About 6% of the cases had wound gaping, 12% each had fever and had hospital stay more than 5 days and 14% of the cases had wound infection in the present study. About 90% of the cases had return of regular menstruation in the present study. Conclusions: The success rate of B Lynch suture was 80% in the present study. There were few post operative immediate complications in our study. Follow up data also suggested that majority of them recovered with normal routine. In our experience, the B-Lynch technique is a safe, effective and easily implemented method of arresting bleeding in cases of major primary PPH due to uterine atony. Keywords: Post partum haemorrhage, Medical methods, Modified B lynch sutures, Atony, Future fertility