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17. My learned predecessor, probably after hearing the case to some extent, in order to understand more about the PPH, summoned Dr.Saraswathi, Director in-charge, Institute of Obstetrics and Gynecology, Government Women and Children Hospital Egmore, and she was examined before this Commission on 5.4.2007. Being an expert, not in dispute, she has given evidence regarding PPH, APH, how it happens, when happens, what are the drugs to be administered, surgical method to be followed, etc., not only by her experience, but also with reference to text books. For better appreciation, we feel the evidence given by her has to extracted as such:

Post-partum hemorrhage is a hemorrhage that occurs during the 3rd stage of labour and after delivery. When the hemorrhage occurs during the 3rd stage of labour, it is called 3rd stage hemorrhage. 3rd stage means stage of placental separation and expulsion. There is one entity called secondary PPH which occurs after 24 hours of delivery.

During normal delivery the expected amount of blood loss will be somewhere around 115 to 230 ML. If it goes beyond 500 ML, it is called PPH.

But according to our standard of women, even 300 ML loss is considered to be PPH in order to take prompt action.

The complications depend upon mainly on the pre-natal health condition of the individual. And even though it is said to be associated with certain pre-disposing factors, sometimes it occurs unexpectedly. So it is a real problem to the Obstetrician. 60% could be anticipated. The pre-disposing factors are anemia in the ante-natal period, over distressed uterus like twins, hydramnios, tumours like Fibroid complicating pregnancy etc. and APH, any anesthetic effect, certain anesthetic drugs, prolonged labour, mismanagement of third stage of labour, certain drugs. These are all causes of atonic PPH where the uterus is not contracting well after the delivery of the baby. There is another category called traumatic PPH, which may be due to any truma in the general tract. Another cause is due to some coagulopathy. These are 3 categories.

If blood is not readily available?

In case blood is not able to be obtained, what should be done?

If the blood is not available, if they have the facility of giving Haemocele, it can be given only for time gaining and the patient has to be referred to higher institution where blood is available.

What text books say is that you should anticipate PPH in 100% of cases. In my view, practically it is not possible to anticipate all case of PPH.

Now a days, it is being instructed to give Oxytocics at the time of delivery of the anterior shoulder of the baby to prevent the blood loss to a minimum. Especially in cases where you anticipate PPH (over distended uterus, anemia without failure) we definitely follow this i.e., giving of Oxytocics at the time of delivery of the anterior shoulder of the baby.