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(f) Paragraph 8 of impugned judgment records the appellants version that the deceased Charanpreet was shifted to the PGI about 05.30 a.m. She was declared dead at 5.45 a.m.

(iv) In para 21 of the impugned judgment a quote from a standard textbook on the subject Obstetrics and Gynecology edited by S.S. Ratnam, K. Bhasker Rao and S. Arulkumaran is reproduced:

Excessive bleeding after childbirth (postpartum hemorrhage or PPH) is the single largest cause of maternal death worldwide. While some bleeding after childbirth is normal and expected, blood loss greater than 500 ml is commonly defined as a marker for PPH. Severe blood loss is dangerous and potentially life threatening. The World Health Organisation (WHO) estimates that 1,50,000 women bleed to death each year as a result of childbirth. PPH accounts for a quarter of all maternal deaths with individual countries reporting percentages of UP to 60%. A woman suffering from PPH can die quickly (Often within 2 hours) unless she receives immediate and appropriate medical care. Every minute of delay raises the likelihood that a woman suffering from hemorrhage will die.

Conclusion: From the above sequence of events, it appears that this patient had atonic PPH, which was managed conservatively but without success. Other management modalities of atonic PPH are surgical intervention including hysterectomy or uterine artery embolisation and immediate shifting to a higher facility for the latter. It is known that Dr. G S Kochhar is himself a qualified anaesthesiologist. It is not mentioned anywhere in the record what resuscitation support system had been provided to the patient at the time of her transportation to the PGI, except that she was on blood transfusion. PPH is a known complication of delivery and accounts for 8% of maternal mortality in developed countries. Different patients may cope differently with blood loss in PPH; a healthy pregnant woman is far more tolerant to blood volume loss of 30-50% than a woman who has pre-existing anaemia, an underlying cardiac complication, or pre-eclampsia. (Reference: Women in developing countries are 40 times more likely than women in developed countries to die in child birth. WHO Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO/RHR/ 00.7. Geneva: WHO, 2000) As such, it cannot be said with certainty from the records whether this patient had anaemia at term or hypotension and shock before delivery or not. However, in the presence of either or both of these conditions, atonic PPH is more likely to be worse and catastrophic.

Preventing Postpartum Hemorrhage:

Active Management of the Third Stage of Labor There are numerous definitions of postpartum hemorrhage (PPH). The most widely recognized definition is blood loss after childbirth in excess of 500 ml. Because it is often difficult to accurately measure blood loss, the true incidence of PPH may be underestimated by up to 50%. The majority of cases of PPH occurs in the immediate postpartum period (within 24 hours after birth) and is due to uterine atony, a failure of the uterus to properly contract after the child is born. As a result, bleeding from the blood vessels in the uterus is not controlled. Without immediate and proper medical attention a woman with PPH will probably die. Anemic women are particularly susceptible to such blood loss. Maternal mortality due to PPH is highest where there is poor access to skilled providers, transport systems and emergency services. This is not surprising considering that a woman will die within two hours, on average, after the onset of PPH if she does not receive proper treatment (e.g., appropriate drugs, blood transfusion or surgical intervention).

1,30,000/-

women bleed to death each year while giving birth. 2/3 women with PPH have no identifiable risk factors.

90% of cases of PPH are due to uterine atony.

Percentage of maternal deaths due to PPH. Sub-Saharan Africa: 25%, West Africa: 27% and Indonesia: 45%.

Following the delivery of the placenta, the uterus is massaged through the abdomen to ensure that it remains contracted.

Uterotonic Drugs Giving women oxytocin immediately after childbirth is probably the single most important intervention used to prevent PPH. Women given oxytocin lose less blood, resulting in a decreased incidence of PPH and anemia. A woman receiving oxytocin delivers her placenta faster and is less likely to require manual removal of her placenta, a painful procedure that increases the risk of infection.