Rajiv Gandhi University of Health Sciences, Karnataka s24

Rajiv Gandhi University of Health Sciences, Karnataka,BangalorePROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECTFOR DISSERTATIONDISSERTATION PROPOSAL“A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE OF NURSESREGARDING PREVENTION AND MANAGEMENT OF POSTPARTUMHAEMORRHAGE DURING THIRD STAGE OF LABOUR IN A SELECTEDMATERNITY HOSPITAL IN BANGALORE WITH A VIEW TO DEVELOPAN INFORMATION BOOKLET.”SUBMITTED BY,Ms. DIVYA ANN GRACE VARGHESE,1ST YEAR M.Sc. NURSING,ROYAL COLLEGE OF NURSING,UTTARAHALLI,BANGALORE.1 Rajiv Gandhi University of Health Sciences, Karnataka,Bangalore.PROFORMA SYNOSPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION1. Name of the Candidate and Ms. DIVYA ANN GRACE VARGHESE, Address. 1ST YEAR M.Sc. NURSING, ROYAL COLLEGE OF NURSING, 7TH MAIN, 1ST BLOCK, UTTARAHALLI, BANGALORE-560061. 2. Name of the Institution. Royal College Of Nursing. 3. Course of study. 1st Year M.Sc. Nursing, Obstetrics & Gynaecological Nursing. 4. Date of admission to course. 31-10-2010. 5. Title of the Topic: “ A Descriptive Study To Assess The Knowledge Of Nurses Regarding Prevention And Management Of Postpartum Haemorrhage During Third Stage Of Labour In A Selected Maternity Hospital In Bangalore With A View To Develop An Information Booklet.” 6. Brief resume of the intended work: 6.1 Need for the study. Enclosed. 6.2 Review of literature. Enclosed. 6.3 Objectives of the study. Enclosed. 6.4 Operational definitions. Enclosed. 6.5 Assumptions. Enclosed. 6.6 Delimitations of the study. Enclosed. 6.7 Pilot study. Enclosed. 6.8 Variables. Enclosed. 7. Materials and methods: 7.1 Sources of data- Data will be collected from nurses working in a selected Maternity Hospitals in Bangalore City.7.2 Methods of data collection- Structured questionnaire.7.3 Does the study require any interventions or investigation to the patients or other human being or animals? No. 7.4 Has ethical clearance been obtained from your institution? Yes ethical committee’s report is here with enclosed. 8. List of references. Enclosed. Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore2 PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION1. Name of the Candidate and Ms. DIVYA ANN GRACE VARGHESE, Address. 1ST YEAR M.Sc. NURSING, ROYAL COLLEGE OF NURSING, 7TH MAIN, 1ST BLOCK, UTTARAHALLI, BANGALORE-560061.2. Name of the Institution. Royal College Of Nursing.3. Course of study and subject. 1st Year MSc. Nursing, Obstetrics & Gynaecological Nursing.4. Date of admission to course. 31-10-2010.5. Title of the Topic: “ A Descriptive Study To Assess The Knowledge Of Nurses Regarding Pre- vention And Management Of Postpartum Haemorrhage During Third Stage Of Labour In A Selected Maternity Hospital In Bangalore With A View To Develop An Information Booklet.”6. BRIEF RESUME OF THE INTENDED WORK:INTRODUCTION3 “An ounce of prevention is worth a pound of care”-Benchemin FranklinThe birth of a baby is a momentous occasion: tiny details of the experiences surrounding the whole event are etched in the memory forever. Of all stages of labour, third stage is the most crucial one for the mother. Foetal complications may appear unexpectedly in an otherwise uneventful first or second stage. Even though third stage lasts only for fifteen to twenty minutes in both primi and multi gravid mothers it can be complicating due to mismanagement of third stage of labour, resulting in maternal mortality. Postpartum haemorrhage-one of the third stage complication is the leading cause of maternal mortality in third world countries.1 Primary postpartum haemorrhage is the bleeding from or into the genital tract or more than 500ml within 24 hours of child birth, 500ml is an arbitrary figure; the effect of bleeding depends upon the rate as well as the amount of blood lost, the previous haemoglobin level of the women and her ability to withstand the blood loss. A pregnant woman has an increased blood volume of 5.3 litres as against4.3 litres in the non pregnant state. This expansion of intravascular compartment enables her to withstand the normal blood loss of third stage of labour. The signs of hypovolaemia and shock develop when the blood volume drops to less than 70% of its pre delivery level. The anaemic woman will deteriorate faster with a blood loss less than 500ml as compared to a woman whose haemoglobin level is sound.2 The contraction and retraction play an important role in the control of third stage haemorrhage, and the uterine muscles (mainly the intermediate myometrial muscle layer) are known as the living ligatures of the uterus. Enhancing the retraction by routine injection of methergin during the third stage reduces the bleeding by 40%, expedites the placental separation and curtails the third stage to less than fifteen minutes.24 Postpartum haemorrhage occurs worldwide and is common in developing countries than developed countries. The occurrence rate is still higher in home deliveries when compared to hospital deliveries. Some of the contributing factors are prevalence of malnutrition and anaemia, inadequate antenatal and intranatal care, lack of blood transfusion facilities, uterine atony, coagulopathies and over distension of uterus.1The best way to prevent postpartum haemorrhage is by active management of third stage of labour and exploration of utero-vaginal canal following difficult labour or instrumental delivery. Antenatal health status of the mother and high risk patient screening is also equally important. Blood grouping is done for all women so that no time is wasted during emergency. Slow delivery of the baby is done, in all cases of induced or accelerated labour by oxytocin: the infusion is continued for at least one hour, examination of placenta and membranes should be done as routine to detect the missing parts.1In the reviews on emergency obstetrics in India, the second most common indication for hysterectomy is uncontrolled postpartum haemorrhage. Gupta et al in their series of 175 cases attributed the indication for hysterectomy to postpartum haemorrhage in 30 cases (17%), atonic PPH, traumatic PPH, secondary PPH together in 9 cases (5.1%). Devi et al in a study reported that atonic PPH is the most common cause in 19.2% cases.36.1 NEED FOR THE STUDY“We need to stop the death of 200,000 women each year from bleeding during childbirth. Alert today- alive tomorrow.”-A. Acosta.5Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide with a prevalence rate of approximately 6%; Africa has the highest prevalence rate of about 10.5%. In Africa and Asia, where most maternal deaths occur, PPH accounts for more than 30% of all maternal deaths. The proportions of maternal deaths attributable to PPH vary considerably between developed and developing countries, suggesting that deaths from PPH are preventable. Interventions to prevent PPH in developing countries are therefore pivotal in the global effort to achieve by 2015 the Millennium Development Goal of reducing maternal mortality ratio by three-quarters.4The most common cause of PPH is uterine atony. Active management of the third stage of labour, which is an evidence-based intervention for the prevention of uterine atony, has been promoted in developing countries. However, both accurate knowledge about active management of the third stage of labour and its correct use remain low in developing countries. The health systems too face enormous constraints that hinder the delivery of emergency obstetric care, which is vital for saving the lives of women who develop PPH. Moreover, there is high prevalence of anaemia among women in developing countries, which complicates PPH. Approximately 65% of deliveries in developing countries are now supervised by a skilled health-care provider. Pragmatic evidence-based interventions are also needed to reduce PPH rates in deliveries not attended by skilled providers.4In 2007, the World Health Organization developed a set of guidelines for the prevention of PPH which recommended the available evidence for various interventions for the different components of active management of the third stage of labour. The interventions are evaluated for their effects on priority outcomes, namely reduction of maternal mortality, reduction of maternal morbidity (blood loss of 1 litre or more and use of blood transfusion) and use of additional uterotonics. Important adverse effects of uterotonic drugs, manual removal of the placenta, are also considered.4 6According World Health Organization (WHO) estimates, every year in India 29.6% of maternal deaths occur due to postpartum haemorrhage. The unacceptably high maternal death ratio (540/100 000 live births) in India during the last few decades remains a major challenge for health systems. According to the WHO estimates, for every maternal death about 20 women suffer from harm to general and reproductive health. In India, around 70% of the population lives in villages and 18 million take place in peripheral areas where maternal and perinatal services are either poor or non-existent. India’s stated goal is to reduce maternal mortality (MMR) from 437 deaths per 100 000 live births that was recorded in 1991 to 109 by 2015. There has been an improvement in the proportion of births attended by skilled health personnel thereby reducing the chances of occurrence of maternal deaths. The efforts to improve maternal health and reduce maternal mortality have been continuous in India since 1960 under the public health program of Primary Health Care – specifically under the Maternal and Child Health (MCH) program. In various policy documents, the government of India has listed the reduction of maternal mortality as one of its key objectives.5A study was conducted by department of obstetrics and gynaecology with the objective to determine the effectiveness of uterine massage after birth and before or after delivery of the placenta, or both, to reduce postpartum blood loss and associated morbidity and mortality. They extracted the data independently using the agreed form. The results show that the numbers of women with blood loss more than 500 ml was small. There were no cases of retained placenta in either group. The mean blood loss was less in the uterine massage group at 30 minutes and 60 minutes after enrolement . The need for additional uterotonics was reduced in the uterine massage group. Two blood transfusions were administered in the control group. Thus the study was concluded that the uterine massage after delivery of the placenta is advised to prevent PPH.67 These studies show that the postpartum haemorrhage is a public health problem even in the developed countries. So, the researcher thought of taking up the task of assessing the knowledge of nurses and helping them in improving their knowledge regarding prevention and management of postpartum haemorrhage in order to reduce further incidence of postpartum haemorrhage in hospitals.Researcher had an experience while working as a staff nurse in an Intensive Care Unit in a reputed hospital in Bangalore, which was the driving force to conduct the study. A primi gravid mother was admitted to the unit with postpartum haemorrhage following childbirth. When investigated, it was found that improper management of third stage had lead to PPH. It proves that the nurses were not following proper active management protocols for third stage. Keeping these facts in mind the researcher felt the real need of conducting a study to assess the knowledge of nurses regarding prevention and management of postpartum haemorrhage.6.2 REVIEW OF LITERATURE“The literature review leads the reader through the development of knowledge about the chosen topic up to the present time to indicate why this current research project was necessary.”7 8 A study was conducted to compare the effectiveness of active versus expectant management of the third stage of labour. The sample was obtained from the Cochrane Pregnancy and Childbirth Group Trials Register, about 6486 women and five studies were conducted. Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour was done. Four compared active versus expectant management, and one compared active versus a mixture of managements. The result depicted that active management reduced the average risk of maternal primary haemorrhage (more than 1000 ml) and of maternal haemoglobin less than 9 g/dl following birth for women irrespective of their risk of bleeding.8A prospective observational study was conducted with the objective to describe the management of severe postpartum. The sampe size was 21,726 deliveries,124 with severe bleeding, who were admitted to the recovery unit of a tertiary referral hospital due to postpartum haemorrhage. The results were that postpartum haemorrhage was more common after an instrumental delivery and after a caesarean delivery. Treatment was provided using packed red blood cells in 96.8% of the patients, fibrinogen in 49.2%, prothrombin complex in 7.25% and activated factor VII in 3.2%. Selective arterial embolization was performed in 10.5% of the cases (success rate, 84.6%) and hysterectomy was required in 13.7%. Conclusions were drawn that the incidence of severe postpartum haemorrhage in patients treated at our hospital is low, as is the mortality rate. Use of fibrinogen is common and provides good results. Angiographic embolization is very effective, though the percentage of hysterectomies is still high.9A study was carried out to examine the effect of oxytocin given prophylactically in the third stage of labour on maternal and neonatal outcomes in 3000 women. All acceptably randomised or quasi-randomised controlled trials including pregnant women were anticipating a vaginal delivery where oxytocin was given prophylactically for the third stage of labour was included. The results showed that prophylactic oxytocin benefits for blood loss > 500 ml and need for therapeutic oxytocics compared to no uterotonics, although there was a non-significant trend towards more manual removal of the placenta which was most marked in the9 expectant management. Conclusions was drawn that oxytocin benefits in terms of postpartum haemorrhage, and there is need for therapeutic oxytocin.10A cohort study was conducted to estimate the effectiveness and safety of the B-Lynch suture for severe persistent postpartum haemorrhage (PPH) following vessel ligation before rendering hysterectomy and its impact on menstruation and uterine cavity. The data were retrieved from medical files and telephone interviews. The results showed that in 13 of the 15 cases (86.7%), PPH occurred after caesarean deliveries and B-Lynch sutures helped to control the haemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause.11 A quasi-experimental study was conducted to evaluate the external aortic compression device (EACD) as a first aid to control postpartum hemorrhage (PPH). The sample of this study was 300 women. The results showed that the regime to stop bleeding was significantly shorter in study women than in control women. 87.5% of study women, but no single woman in the control group had their bleeding stopped within the first 45 min of PPH onset. Thus study was concluded that the EACD is a cost-effective and easily applied maneuver that allows satisfactory management of PPH without maternal mortality or morbidity.12A study on systematic review of published randomized controlled trials and relevant reviews was conducted to review the literature to determine the most effective methods for preventing postpartum haemorrhage. The results demonstrated10 that the review of the literature confirms that active management of the third stage of labour, especially the administration of uterotonic drugs, reduces the risk of PPH due to uterine atony without increasing the incidence of retained placenta or other serious complications. Oxytocin is the preferred uterotonic drug compared with syntometrine, but misoprostol also can be used to prevent hemorrhage in situations where parenteral medications are not available (e.g. at home births in developing countries).And hence, concluded that the use of active management of the third stage of labor to prevent PPH due to uterine atony should be expanded, especially in developing country setting.13A study was conducted to assess the effectiveness and safety of pharmacological and surgical interventions used for the treatment of primary postpartum haemorrhage. Randomised or quasi-randomised controlled trials were done. Samples were obtained from the Cochrane Pregnancy and Childbirth Group's trials register. Trial was done to compare rectal administration of misoprostol versus syntometrine combined with an oxytocin infusion. Again a comparison done between a combination of intramuscular syntometrine injection and oxytocin infusion, rectal misoprostol was done. However, there was no significant difference between the two groups regarding surgical interventions to control intractable haemorrhage including hysterectomy, internal iliac artery ligation and/or uterine packing. Hence it was concluded that rectal misoprostol in a dose of 800 micrograms could be a useful 'first line' drug for the treatment of primary postpartum haemorrhage.14A study was conducted to determine current clinical practice among different maternity units in the United Kingdom for the management of major postpartum haemorrhage with the help of a questionnaire in 199 hospitals in UK. The results showed that there was a lack of agreement between the different units regarding the definition and interventions for major postpartum haemorrhage. The majority of the units use oxytocin, ergometrine and carboprost as a 'first-line' for the treatment of postpartum haemorrhage. Hysterectomy was the most common surgical procedure. There was a lack of agreement regarding the use and choice of thromboprophylaxis11 following surgery for major haemorrhage .Thus it was concluded that current management of major postpartum haemorrhage varies considerably.15 A study was conducted to determine the effectiveness and safety of prophylactic use of ergot alkaloids in the third stage of labour compared with no uterotonic agents, as well as with different routes or timing of administration for prevention of postpartum haemorrhage. They included six studies comparing ergot alkaloids with no uterotonic agents, with a total of 1996 women in ergot alkaloids group and 1945 women in placebo or no treatment group. The use of injected ergot alkaloids in the third stage of labour significantly decreased blood loss and postpartum haemorrhage of at least 500 ml. Hence it was concluded that prophylactic intramuscular or intravenous injections of ergot alkaloids are effective in reducing blood loss and postpartum haemorrhage.16A study was conducted to obtain a systematic review of measured postpartum blood loss with and without prophylactic uterotonics for prevention of postpartum haemorrhage. The sample size is 29 studies. The result shows that the distribution of average blood loss is similar with any prophylactic uterotonic, and is lower than without prophylaxis. Compared with oxytocin and misoprostol, oxytocin has lower PPH and severe PPH rates than misoprostol, but not in developing countries. Thus the study was concluded that oxytocin is superior to misoprostol in hospitals.17A study was conducted to assess the use of B-Lynch type uterine compression sutures as an alternative to hysterectomy for severe postpartum hemorrhage (PPH) due to uterine atony in 7 cases, reviewed over a 30-month period in a tertiary obstetric unit. The results showed that in 7 cases of uterine atony at the time of Caesarean section, which were unresponsive to all oxytocic agents, a B-Lynch type compression suture was used before resorting to hysterectomy. In 6 of the 7 women,12 the bleeding was controlled with the suture, while the other required hysterectomy. Thus concluded that compression suture is easy to apply and should be considered in cases of severe atonic PPH when oxytocic agents fail, and before resorting to hysterectomy.18A retrospective study is carried out to know the prevalence of postpartum haemorrhage. The sample size consists of all the patients admitted with PPH or developed PPH within hospital from 1st Jan-31st Dec 2006 are included. Exclusion criteria were patients with bleeding disorders and on anticoagulants. The results show that Uterotonics used for prophylaxis in 30, for treatment of PPH, 106. Patients delivered by traditional birth attendants 70, lady health workers 40 & doctors 26. Uterine massage performed in 30, minor surgical procedures 33, manual removal of retained placenta, 11, hysterectomy, 50 & compression sutures were applied in 3. Maternal deaths due to PPH were 6. Thus this study was concluded that PPH can be prevented by avoiding unnecessary inductions/augmentations of labour, risk factors assessment and active management of 3rd stage of labour. It needs critical judgment, early referral and early resuscitation by birth attendant.196.3. OBJECTIVES OF THE STUDY13 1. To assess the knowledge of nurses regarding prevention and management of postpartum haemorrhage in third stage among mothers.2. To find out the association between knowledge scores and selected demographic variables.3. To prepare an information booklet regarding prevention and management of postpartum haemorrhage during third stage.6.4. OPERATIONAL DEFINITIONS1. Assess- Assess refers to process of the critical analysis and valuation and judgement of the status or quality regarding prevention and management of postpartum haemorrhage in third stage.2. Knowledge- Knowledge refers to the nurse’s intellectual ability to answer the questions regarding prevention and management of postpartum haemorrhage on administering questionnaire.3. Prevention- The action directed to preventing the occurrence of postpartum haemorrhage by giving proper care through active management of third stage.4. Management- Management refers to the care given by nurses to the mother undergoing labour.5. Postpartum haemorrhage- Postpartum haemorrhage is the bleeding from or into the genital tract or more than 500ml within 24 hours of child birth.6. Third stage- The period from delivery of foetus till complete expulsion of placenta and its membranes.7. Mother- A women who is undergoing the labour process.8. Nurses- A nurse is a member of health team who is alongside and supporting women giving birth. 14 9. Information booklet- It is a small book with a paper cover containing information about prevention and management of postpartum haemorrhage.6.5. ASSUMPTIONS1. Nurses may have some knowledge regarding prevention and management of postpartum haemorrhage in third stage.2. Nurse’s knowledge regarding prevention and management of postpartum haemorrhage in third stage can be measured by using a structured knowledge questionnaire.3. Nurse’s knowledge regarding prevention and management of postpartum haemorrhage in third stage can be improved by an information booklet.6.6. DELIMITATIONS OF THE STUDY1. The study is limited to nurses working in selected maternity hospital, Bangalore.2. The study is limited to nurses who have experience ranging till 5 years.6.7 PILOT STUDYThe study will be conducted with 6 samples. The purpose to conduct the pilot study is to find out the feasibility for conducting the study and design on plan of statistical analysis.15 6.8. VARIABLESA variable is any measured characteristic or attribute that differs for different subjects.Dependent variable: Knowledge level of nurses regarding prevention and management of postpartum haemorrhage during third stage of labour.Independent variable: Information bookletExtraneous variable: qualification of nurse, years of experience, age, course attended regarding prevention and management of postpartum haemorrhage.7.0. MATERIAL AND METHODS7.1. SOURCE OF DATAThe data will be collected from nurses who are working in selected maternity hospital, Bangalore.7.1.1. RESEARCH DESIGNNon-experimental designThe research approach adopted for this study is descriptive in nature.7.1.2. RESEARCH APPROACHDescriptive survey approach.7.1.3. SETTING OF THE STUDYThe physical location & condition in which data collection takes place in the study is known as setting.The study will be conducted in selected maternity hospital in Bangalore.16 7.1.4. POPULATIONAll nurses who meet the inclusion criteria and are working in a selected maternity hospital in Bangalore.7.2. METHOD OF COLLECTION OF DATA (INCLUDING SAMPLING PROCEDURE)The data collection procedure will be carried out for a period of one month. The study will be conducted after obtaining permission from concerned authorities. The investigator will collect data from nurses by using a knowledge questionnaire to assess knowledge regarding prevention and management of postpartum haemorrhage during child birth. Data collection instruments consist of the following sectionsSection ‘A’: Questions related to demographic data.Section ‘B’: Questions to assess the knowledge regarding prevention and management of postpartum haemorrhage among nurses.7.2.1. SAMPLING TECHNIQUESampling technique adopted for the selection of sample is non-probability convenience sampling.7.2.2. SAMPLE SIZEThe sample consists of 60 nurses working in selected maternity hospital, Bangalore.17 SAMPLING CRITERIA7.2.3. INCLUSION CRITERIA1. Nurses who are working in the selected maternity hospital.2. Nurses who are willing to participate in the study.3. Nurses who have experience ranging till 5 years.4. Nurses who are not selected for the pilot study.7.2.4. EXCLUSION CRITERIA1. Nurses who are selected for pilot study.2. Nurses who are not available at the time of study.3. Nurses who are not willing to participate in the study.7.2.5. TOOL FOR DATA COLLECTIONA structured knowledge questionnaire is used to collect the data from the nurses working in selected maternity hospital in Bangalore.7.2.6. DATA ANALYSIS METHODThe data collected will be analysed by using descriptive and inferential statistics. Descriptive statistics: Frequency and percentage will be used for analysis of demographic data and mean, mean percentage and standard deviation will be used for assessing the level of knowledge regarding prevention and management of postpartum haemorrhage.18  Inferential statistics: Chi-square test will be used to find association between knowledge and selected demographic variables.7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?Since the study design is descriptive in nature, investigation or interventions are not required.7.4. ETHICAL CLEARENCEYes, the ethical committee’s report is here with enclosed. The main study will be conducted after the approval of research committee of the college. Permission will be obtained from the head of the institution. The purpose and details of the study will be explained to the study subjects and assurance will be given regarding the confidentiality of the data collected.19 8. LIST OF REFERENCES: [VANCOUVER STYLE FOLLOWED]:1. D.C.Dutta. Text Book of Obstetrics including perinatology and contraception. Sixth ed. 2004, New Central Book Agency (p) ltd., Pg: 411-413.2. V Padubidri, Ela Anand. Textbook of Obstetrics. B.I.Publications (P) ltd. Pg: 367-368.3. Article on emergency obstetrics in India. Available from URL: http://www.pubmed .com. 4. Fawole B, Awolude O A, Adeniji A O, Onafowokan O. Article available from RHL The WHO Reproductive Health Library. Available from URL: http:// apps.who.int/rhl/effective_practice_and_organizing_care/guidance_pphpreven tion_fawoleb/en/in. 20 5. D. S. Shah, H. Divakar and T. Meghal. Article on combating postpartum haemorrhage in India: Moving Forward. http://www.glowm.com/? p=glowm.cml/ safer_motherhood_contents. Available from URL: http://www.sapiens publishing.com/ pph_pdf/ PPH-Chap-49.pdf.6. Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006431. Available from URL: http://www.ncbi.nlm.nih.gov/pub med /18646154. 7. Diane.M. Fraser, Margaret A Cooper. Myles text book for midwives.ed 14,2003. Elsevier publications. Pg:72.8. Begley C M, et al. Active versus expectant management for women in third stage of labour. Cochrane Database Syst Rev. 2010 Jul 7; (7):CD007412. Available from URL: http://www. ncbi.nlm.nih.gov/pubmed /20614458.9. Guasch E, Alsina E, Díez J, Ruiz R, Gilsanz F.Post partum haemorrhage: an observational study of 21,726 deliveries in 28 months.. Rev Esp Anestesiol Reanim. 2009 Mar;56(3):139-46. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed / 19408780.10. Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in third stage of labour. Cochrane Database Syst Rev. 2001; (4): CD001808. Available from URL: http: //www .ncbi.nlm.nih.gov/pubmed /11687123. 11. Sentilhes L, et al. B-Lynch suture for massive persistent postpartum haemorrhage following stepwise uterine devascularization. Acta Obstet21 Gynecol Scand. 2008;87(10):1020-6. Comment in:Acta Obstet Gynecol Scand. 2009;88(4):489-90; author reply 490-2. Available from URL: http: //www.ncbi. nlm.nih. gov/pubmed / 18927949 .12. Soltan MH, Faragallah MF, Mosabah MH, Al-Adawy AR. External aortic compression device: the first aid for postpartum haemorrhage control. J Obstet Gynaecol Res. 2009 Jun; 35(3):453-8. Available from URL: http: //www.ncbi.nlm.nih. gov/pubmed / 19527382 .13. McCormick ML, Sanghvi HC, Kinzie B, McIntosh N. Preventing postpartum haemorrhage in low resource settings. Int J Gynaecol Obstet. 2002 Jun; 77(3):267-75. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed /12065142. 14. Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2007;(1):CD003249. Available from URL: http:// www. nc bi.nlm.nih.gov/pubmed / 17253486. 15. Mousa HA, Alfirevic Z. Major postpartum haemorrhage: survey of maternity units in the United Kingdom. Acta Obstet Gynecol Scand. 2002 Aug; 81(8):727-30. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed / 12174156 . 16. Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Prophylactic use of ergot alkaloids in the third stage of labour. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005456. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/17443 592. 22 17. Sloan NL, Durocher J, Aldrich T, Blum J, Winikoff B. What measured blood loss tells us about postpartum bleeding: a systematic review. PMC2878601Free PMC Article BJOG. 2010 Jun; 117(7):788-800. Epub 2010 Apr 20. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed / 20406227 .18. Smith KL, Baskett TF. Uterine compression sutures as an alternative to hysterectomy for severe postpartum haemorrhage. J Obstet Gynaecol Can. 2003 Jun; 25(6):456; author reply 458. Available from URL: http://www.ncbi.nlm.nih.gov /pubmed /12610671. 19. Bibi S, Danish N, Fawad A, Jamil M. An audit of primary postpartum haemorrhage. J Ayub Med Coll Abbottabad. 2007 Oct-Dec; 19(4):102-6. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed / 18693611 .23 9. Signature of the candidate.10 Remarks of the guide.11. Name and designation. 11.1 Guide 11.2 Signature 11.3 Co-guide 11.4 Signature 11.5 Head of the department 11.6 Signature12. 12.1 Remarks of the chairman and principal. 12.2 signatures.24

Rajiv Gandhi University of Health Sciences, Karnataka s24

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