The three components of the active management of third stage of labour

(AMTSL):

1. Oxytocic drugs should be offered routinely in the management of the third

stage of labour in all women. Prophylactic oxytocic drugs have been found to reduce the
risk of PPH by about 60%.  If oxytocin is not available, oral misoprostol should be given.
Misoprostol can be given by community health worker (ASHA) who may be present in the
community during home delivery cases*.

If bleeding is not controlled after use of oxytocin, it is recommended to switch over to the next
uterotonic ergot derivatives (methergine) or sublingual misoprostol. (Ergot derivatives
(methergine) are contradindicated in hypertensive disorders for the prevention of PPH).

2. Late cord clamping (performed approximately 1 to 3 minutes after birth) is recommended for
all births while initiating simultaneously essential new-born care.

3. Controlled cord traction is the recommended method for the removal of the placenta. Uterine
massage following the delivery of the placenta is included in AMTSL, where skilled birth
attendants are available.

Management of Postpartum haemorrhage-

Initial assessment is performed and basic treatment should be instituted as follows:

1. Call for help

2. Assess airway, breathing, circulation (ABC)
3. Provide supplementary oxygen
4. Obtain intravenous line
5. Start fluid replacement with intravenous crystalloid fluid
6. Monitor blood pressure, pulse and respiration
7. Catheterize bladder and monitor urinary output
8. Assess need for blood transfusion
9. Start intravenous oxytocin infusion
10. Order laboratory tests-complete blood count, coagulation screen, blood grouping
and cross-match

Observe factors related to bleeding and determine cause,

(a) If uterine atony is suspected:

 Uterine massage; ((Uterine packing is not recommended for the treatment of PPH due to
uterine atony after vaginal delivery);
 bimanual uterine compression;
  external aortic compression; and
 balloon or condom tamponade.

If the woman is not responding to the treatment or a treatment cannot be administered at the
facility, she should be transferred to a higher-level facility with on-going intravenous uterotonic
infusion, legs elevated to improve blood supply to vital organs and keep the woman worm.
Accompanying attendant should rub the woman’s abdomen continuously and, if necessary, apply
mechanical compression.

If mechanical and pharmacological measures fail to control the haemorrhage, surgical

measures are instituted:

 Compression sutures
 Bilateral ligation of uterine arteries
 Bilateral ligation of internal iliac (hypogastric) arteries
 Hysterectomy

(b) If Placenta delivered incomplete

 Oxytocin
 Manual exploration to remove fragments
 Gentle curettage or aspiration
 If bleeding continues, manage as uterine atony.

(c) If placenta is not delivered:

 Additional oxytocin in combination with controlled cord traction

If whole placenta still retained

 Manual removal with prophylactic antibiotics

(d) PPH due to lower genital tract trauma : excessive bleeding or shock with contracted
uterus-

 Look for lower genital tract trauma with repair of tears; and evacuation and repair of
haematoma.
 If bleeding continues administer tranexamic acid.

(e) Uterine rupture or dehiscence: excessive bleeding or shock-

  Treat for uterine rupture or dehiscence with laparotomy for primary repair of uterus and
Hysterectomy if repair fails.
 If bleeding continues administer tranexamic acid.

(f) Uterine inversion: uterine fundus not felt abdominally or visible in vagina-

Treat for uterine inversion: 

 Immediate manual replacement

 Hydrostatic correction
 Manual reverse inversion (use general anaesthesia or wait for effect of any uterotonic to
wear off)
 If treatment is not successful, laparotomy is advised to correct inversion.
 If laparotomy correction is not successful then hysterectomy is performed.

(g) Clotting disorder: bleeding in the absence of above conditions, Treat for clotting disorder
as necessary with blood products.

Secondary PPH is the abnormal or excessive bleeding from the birth canal between 24 hours
and 12 weeks postnatally. It is often associated with infection (endometritis) and conventional
treatment involves antibiotics and uterotonics.

Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective

of ultrasound findings.

References-

apps.who.int/iris/bitstream/10665/44171/1/9789241598514_eng.pdf

www.gfmer.ch/omphi/pph/pdf/pph.pdf

* http://nrhm.gov.in/images/pdf/programmes/maternal-health/guidelines

The prevention and treatment of PPH are vital steps towards improving the health care of women
during childbirth and the achievement of the Millennium Development Goals.

 Women and adolescents are the most powerful agents for improving their own health and
achieving prosperous and sustainable societies. All adolescents should be given health
education to realize their rights to health, well-being, education and full and equal participation in
society. Promote health education to couples to make them understand the importance of
antenatal checkups, hospital deliveries and small family norms with expectation of supportive
attitude and behavior from male partners.
 During pregnancy, each pregnant woman should be investigated for anaemia and treated
appropriately as this may reduce the occurrence and morbidity associated with PPH.

 At the household level, ASHA/ANM (accredited social health activists/auxiliary nurse

midwife) sensitizes the key decision makers and pregnant women for timely access to health
services through pre-identified transport facility. Risk factors for PPH may present antenatally or
intrapartum; hence birth preparedness and complication readiness (BPCR) plan must be
prepared and may be modified as and when risk factors arise.

 Pregnant women and her relatives should be encouraged for institutional delivery.
Women with known risk factors for PPH should only be delivered in a hospital with a blood bank
on site. In cases where, for some reason, the woman is unable to access the health facility at the
time of delivery and home delivery is imminent; the ANM or any other skilled birth attendant
should conduct this delivery. In home deliveries where ANMs cannot attend to the women,
ASHAs have been allowed to undertake advance distribution of misoprostol to pregnant women
in the 8th month of pregnancy, for self-administration just after childbirth, for prevention of PPH*.

 PPH need to be reduced by strengthening peripheral delivery facilities, active third stage
management and early referral. Though the institutional deliveries are increasing in the country;
the capacity of the system to address obstetric emergencies and resultant life threatening
complications needs to be strengthened.

 Ministry of Health and Family Welfare, Government of India  has released

guidelines as “Guidance Note on Prevention and Management of Postpartum
haemorrhage”* and promoted the concept of Obstetric High Dependency Units (HDU) and
Obstetric Intensive Care Units (ICU) ** in the country. It is suggested that all District
Hospitals should have an Obstetric HDU and all the Medical Colleges should have both an
obstetric HDU and an obstetric ICU (or ICU with dedicated obstetric beds). Subsequently based
on the availability of resources, the states can set up obstetric HDUs in high delivery load
facilities such as community health centers and block primary health centers (CHCs and block
PHCs).

References-

www.who.int/pmnch/media/events/2015/gs_2016_30.pdf

www.who.int/maternal_child_adolescent/documents/MPSProgressReport09-FINAL.pdf

www.who.int/maternal_child_adolescent/documents/MPSProgressReport09-FINAL.pdf

www.who.int/whr/2005/chapter4/en/index1.html 
* nrhm.gov.in/images/pdf/programmes/maternal-
health/guidelines/Guidance_Note_on_Prevention_&_Management_of_Postpartum_Haemorrhag
e.pdf

** nrhm.gov.in/images/pdf/programmes/maternal-
health/guidelines/Guidelines_for_Obstetric_HDU_and_ICU.pdf

Postpartum haemorrhage (PPH) is a complication of delivery and the most common cause
of maternal death, accounting for about 35% of all maternal deaths worldwide. These deaths
have a major impact on the lives and health of the families affected.

PPH is commonly defined as a blood loss of 500 ml or more within 24 hours after birth, while
severe PPH is defined as a blood loss of 1000 ml or more within the same timeframe according
to World Health Organisation (WHO). A small blood loss that makes the woman
haemodynamically unstable is also termed as PPH.

PPH is a major cause of morbidity and mortality with in the first 24 hours following delivery and
this is regarded as primary PPH; whereas any excessive bleeding from the birth canal occurring
between 24 hours and 12 weeks postnatally (after delivery) is termed as secondary PPH.

In practice, blood loss after delivery is seldom measured and it is not clear whether measuring
blood loss improves the care and outcome for the women. In addition, some women may require
interventions to manage PPH with less blood loss than others if they are anaemic.

PPH may result from failure of the uterus to contract adequately (atony), genital tract trauma
(vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal bleeding
disorders. Uterine atony is the most common cause and consequently the leading cause of
maternal mortality worldwide.

The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live births versus
12 per 100 000 live births in developed countries. Thus 99% of all maternal deaths occur in
developing countries with more than half of these deaths occur in sub-Saharan Africa and almost
one third occur in South Asia.  Very small proportion, 1% of maternal deaths occur in the
developed world. There are large disparities between countries, but also within countries;
maternal deaths are more in low income group and rural areas as compare to high income group
and urban areas.

About 830 women die from pregnancy or childbirth-related complications around the world every
day. 52% of maternal deaths are attributable to three leading preventable causes-haemorrhage,
sepsis, and hypertensive disorders. WHO statistics suggest that 25% of maternal deaths are due
to PPH. Postpartum bleeding is the quickest of maternal killers; can kill even a healthy woman
within two hours, if not treated. 
Incidence of PPH is reported as 2% - 4% after vaginal delivery and 6% after cesarean section;
with uterine atony being the cause in about 50% cases. Every year about 14 million women
around the world suffer from PPH.

In India sample registration scheme (SRS), during survey of causes of death 1998, reported that
PPH was a major cause of maternal mortality and responsible for 30 % of maternal deaths and
according to SRS 2001-2003, PPH accounts 38 percent of maternal deaths. Estimates of
maternal mortality ratio in India done by Indian Council of Medical Research (ICMR) in 2003 also
showed PPH as a leading cause of maternal mortality in study population.   

A combination of quality antenatal care, skilled care at birth by active management of third stage
of labour, the availability of high quality emergency obstetric care (with trained medical personnel
and adequate infrastructure) and improved access to these services are essential to save many
maternal lives.

References-

www.who.int/maternal_child_adolescent/documents/MPSProgressReport

www.who.int/mediacentre/factsheets/fs348/en/

www.who.int/medicines/areas/priority_medicines/Ch6_

emedicine.medscape.com/article/275038-overview#a5

www.ncbi.nlm.nih.gov/pmc/articles/PMC3688110/

planningcommission.nic.in/aboutus/committee/strgrp/stgp_

www.icmr.nic.in/final/Final%20Pilot%20Report.pdf

file.scirp.org/pdf/OJOG_2015092116115550.pdf

www.unmillenniumproject.org/documents/TheLancetChildHealthMaternalHealth.pdf

www.who.int/pmnch/media/events/2015/gs_2016_30.pdf

nrhm.gov.in/images/pdf/programmes/maternal-health/guidelines/

PROBLEM STATEMENT

1. A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE

REGARDING IRON DEFICIENCY ANEMIA AND ITS
 PREVENTION AMONG PREGNANT WOMEN IN SELECTED
HOSPITAL JODHPUR.

Objectives:
1. To assess the knowledge regarding iron deficiency anemia and its prevention among
pregnant women.
2. To find out association between knowledge regarding iron deficiency anemia and its
prevention with their selected socio-demographic variables

Need of study:
 Anemia is one of the most common nutritional deficiency disorders affecting the
pregnant women; the prevalence in developed countries is 14%, in developing
countries 51%, and in India, it varies from 65% to 75%.
 Anemia is a common medical disorder in pregnancy which is accompanied with poor
maternal and perinatal outcome. It is one of the most important health problems
among women at the age range of 18-45 year in the world.
 Anemia during pregnancy is considered one of the main risk factors contributing 20-
40% of maternal deaths in direct or indirect way through preeclampsia, cardiac
failure, APH, PPH and puerperal sepsis; as well as to low birth weight which
contributes to increase of infant mortality in developing countries.
 During pregnancy, severe cases of pregnant women of iron deficiency have poor
outcome of neonates as low birth weight, intrauterine growth retardation, prematurity,
birth asphyxia and intrauterine death.
 Anemia in the third world affects 30% of population and IDA accounts for75% of all
types.
 It is a main cause of morbidity for women of reproductive age, but little is known
about knowledge and practice related to screening and management of this problem.
 The risk of IDA anemia increased with the gravidity decreased birth spacing,
gestational age, drinking tea and coffee after meals and decreased intake of proteins
and low level of knowledge and income.
 The aim of study is aimed at evaluating the knowledge and practices regarding
prevention of IDA among pregnant women attending selected hospital jodhpur.
 It is estimated worldwide that 41.8% of pregnant and 30.2% of non-pregnant women
are anemic. The WHO has estimated that the prevalence of anemia in pregnant
women is 14% in developed and 51% in developing countries. It is painful to mention
that India contributes to about 80% of the maternal deaths due to anemia in South
Asia.
PROBLEM STATEMENT

2. A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE

REGARDING PREVENTION OF URINARY TRACT INFECTION
 AMONG PREGNANT WOMEN IN SELECTED HOSPITAL
JODHPUR.

Objectives:
1. To assess the knowledge regarding prevention of urinary tract infection among
pregnant women.
2. To find out association between knowledge regarding prevention of urinary tract
infection among pregnant women with their selected socio-demographic variables

Need of study:
 Urinary tract infection is more commonly seen in primigravida than multiparous.
Ignorance about the potential of this health hazard also constitutes a barrier that
prevents the initiation of preventive and remedial measures at appropriate time.
 Comparing to the urban population most of the pregnant women belonging to rural
area are still not aware about this. Previous history of urinary tract infection increases
the chance of recurrent infection by 50% presence of asymptomatic in pregnancy on
routine screening. If not detected early and treated promptly, this infection
complicates 1-3% of all pregnancies.
 As per WHO report, 20-50% of pregnant women will experience bacteria in their
pregnancy. 5-10% of them are getting expose in their first pregnancy.

PROBLEM STATEMENT

3. A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED

TEACHING PROGRAMME ON VAGINITIS AND ITS PREVENTION
AMONG WOMEN IN SELECTED HOSPITAL JODHPUR.
Objectives:
1. To assess the level of knowledge of women regarding vaginitis and its prevention
before planned teaching programme as measured by a structured knowledge
questionnaire.
2. To evaluate the effectiveness of PTP on vaginitis and its prevention in terms of gain
in knowledge scoring using a structured knowledge questionnaire.
3. To find the association between the level of knowledge scores before PTP and
selected demographic variables.

Need of study:
 Reproductive tract infections (RTIs), generally seen as a silent epidemic, is one of the
major public health problems causing a considerable proportion of gynecological
morbidity and maternal mortality in the developing countries.
 Vaginitis is considered the most common type of reproductive system infections and
refers to any inflammation or infection of the vagina. This is a common gynecological
problem found in women of all ages, with most having at least one form of vaginitis
at sometime during their life. Vaginitis can occur when the walls of the vagina
become inflamed or some irritant has disturbed the balance of the vagina.
 According to WHO, the prevalence of vaginitis is 10-25%. Vaginitis affects at least
one third of all women during their life time. 10% vaginitis is seen among adolescents
in worldwide. In India the prevalence of vaginitis is21-32%.

PROBLEM STATEMENT

4. A STUDY TO ASSESS THE KNOWLEDGE REGARDING

PUERPERAL INFECTION AND ITS PREVENTION AMONG
 PRIMIGRAVIDA MOTHERS IN SELECTED HOSPITAL AT
JODHPUR.

Objectives:
1. To assess the knowledge regarding prevention of puerperal infection among
primigravida mothers.
2. To find out association between knowledge regarding prevention of puerperal
infection among primigravida mothers with their selected socio-demographic
variables.

Need of study:
 Puerperal infection is one of the leading causes of mortality and morbidity of women
in postnatal period. It is known that the delivery type, the insufficient notification of
postpartum infections cases due to lack of surveillance after discharge, the early
discharge of puerperal women and the patients return’s outside the institution where
the delivery occurred, as well as environmental, individual and maternal factors have
been related with the incidence of puerperal infections.
 With the advent of improved hygienic practices and the introduction of antibiotics,
morbidity and mortality from puerperal infection has decreased significantly and
infection is no longer the leading cause of maternal mortality.
 In India, maternal deaths from puerperal sepsis are accounting for approximately 15%
of all maternal deaths.
 A sixteen year study from northern India found that sepsis was responsible for over
35% of maternal deaths and a study in southern India revealed that sepsis was a
leading cause of maternal death responsible for 41.9% of deaths. Demographic and
health survey shows that the majority of women do not receive a postnatal check-up
and 14% of women who had a birth in the last 5 years reported very high fever in the
postpartum period.
 Education and knowledge is very important for the safe motherhood. It is essential to
educate the mothers properly to make them aware of the care before, during
pregnancy and after delivery to prevent complications and reduce the maternal
morbidity and mortality rate.

PROBLEM STATEMENT
 5. A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON KNOWLEDGE REGARDING
GESTATIONAL DIABETES DURING PREGNANCY AMONG
PRIMIGRAVIDA MOTHERS ATTENDING A.N.C CLINIC AT
SELECTED HOSPITAL JODHPUR.

Objectives:
1. To assess the knowledge regarding gestational diabetes during pregnancy.
2. To evaluate the effectiveness of structured teaching programme on gestational
diabetes during pregnancy.
3. To correlate the knowledge regarding gestational diabetes during pregnancy with the
demographic data of antenatal mothers.

Need of study:
 Diabetes is a major public health problem in India with prevalence rates
reported to be between 4.6% and 14% in urban areas, and 1.7% and 13.2% in
rural areas.
 India has an estimated 62 million people with Type 2 diabetes mellitus (DM);
this number is expected to go up to 79.4 million by 2025.
 Gestational diabetes mellitus (GDM) affects up to 5% of all pregnancies in the
UK between 1% and 25% of pregnancies globally, and its incidence is
increasing .
 GDM is associated with an increased risk of adverse fetal, infant and maternal
pregnancy outcomes including preeclampsia, primary caesarean section,
excessive fetal growth (large for gestational age or macrosomia), shoulder
dystocia or birth injury, neonatal hypoglycaemia, and admission to neonatal
intensive care.
 It can be improved by interventions directed at reducing blood glucose during
pregnancy. These include self-monitoring of blood glucose, lifestyle changes
and the use of glucose lowering therapies such as metformin and insulin.
 The aim of study to enhance the knowledge of gestational diabetes during
pregnancy among primigravida mother.