Documentation code:

Apollo Hospitals - AP/CQI.7/CAR/01

Visakhapatnam
Prepared date: December
Clinical Audit Report 16/12/2021

Reference: CQI.7.NABH Standards – Submitted date:

th 21/01/2022
5 Edition

Topic: - Primary PPH monitoring in elective LSCS patients during first hour after
the procedure in recovery room.

Background: PPH is the most common cause of maternal death worldwide. One
of the Millennium Development Goals set by the United Nations in 2000 is to reduce
maternal mortality by three-quarters by 2015. If this is to be achieved, maternal
deaths related to postpartum hemorrhage (PPH) must be significantly reduced.

Introduction:
PPH is generally defined as blood loss greater than or equal to 500 ml within 24
hours after birth, while severe PPH is blood loss greater than or equal to 1000 ml
within 24 hours. PPH is the most common cause of maternal death worldwide. Most
cases of morbidity and mortality due to PPH occur in the first 24 hours following
delivery and these are regarded as primary PPH whereas any abnormal or excessive
bleeding from the birth canal occurring between 24 hours and 12 weeks postnatally
is regarded as secondary PPH.

PPH may result from failure of the uterus to contract adequately (atony), genital tract
trauma (i.e. 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.
Most cases of morbidity and mortality due to PPH occur in the first 24 hours
following delivery and these are regarded as primary PPH whereas any abnormal or
excessive bleeding from the birth canal occurring between 24 hours and 12 weeks
postnatal is regarded as secondary PPH.

Aim:
The aim of the audit is to know the current practices in hospital for PPH monitoring
in elective LSCS patient during first hour after the procedure in recovery room.
 Documentation code:
Apollo Hospitals - AP/CQI.7/CAR/01
Visakhapatnam
Prepared date: December
Clinical Audit Report 16/12/2021

Reference: CQI.7.NABH Standards – Submitted date:

th 21/01/2022
5 Edition

Objective:-
100% primary PPH monitoring during first hour after the procedure in recovery
room in elective LSCS patients.

Parameter 100% primary PPH monitoring during

first hour after the procedure in
recovery room in elective LSCS
patients.
Exceptions NIL
Standard 100%

Methodology: Retrospective Study of Elective LSCS cases in the department of

obstetrics in our hospital in between July to November 2021. All the obstetrics
patients undergoing Elective Lower Segment Caesarian Section were selected for
primary PPH monitoring during first hour after the procedure in recovery room. The
details of PPH monitoring were analyzed from the case sheets of the respective
patient’s medical records.

Audit type: Retrospective Study of Elective LSCS cases.

Files of these cases were selected from MRD. The team reviewed all the case files
for primary PPH monitoring. After reviewing all the files excel sheet was prepared
for all selected cases according to the criteria of audit. Result & compliance % were
drawn & discussed with the concern team and specialty doctors. Review meeting
held with Medical superintendent, Deputy Medical Director and doctors.

Results: Total numbers of patients evaluated was 37.

 Documentation code:
Apollo Hospitals - AP/CQI.7/CAR/01
Visakhapatnam
Prepared date: December
Clinical Audit Report 16/12/2021

Reference: CQI.7.NABH Standards – Submitted date:

th 21/01/2022
5 Edition

Twenty four (63%) patients had monitored for Primary PPH during first hour after
the procedure in recovery room.
Fourteen (37%) patients were not monitored for Primary PPH during first hour after
the procedure in recovery room.

37%
Done
Not Done

63%

Comparison with standard:-

Postpartum hemorrhage (PPH) describes excessive bleeding after the delivery of a
fetus. It is the leading cause of maternal death, responsible for approximately 68,500
deaths a year, 99.7% occurring in developing regions. It occurs in approximately 6%
of deliveries when defined as a blood loss equal to or greater than 500 ml, or 1–2%
when 1000 ml is used. It, therefore, represents a significant global health burden,
disproportionately affecting those in the world's poorest countries.
The overall prevalence of PPH worldwide is estimated to be 6 to 11 percent.5 Rates
vary by data source and country as well as assessment method with a prevalence of
10.6 percent when measured by objective appraisal of blood loss and 7.2 percent
when assessed with subjective techniques. A systematic review estimated the
prevalence of PPH with 500 mL of blood loss or more at 10.5 percent in Africa, 8.9
 Documentation code:
Apollo Hospitals - AP/CQI.7/CAR/01
Visakhapatnam
Prepared date: December
Clinical Audit Report 16/12/2021

Reference: CQI.7.NABH Standards – Submitted date:

th 21/01/2022
5 Edition

percent in Latin America and the Caribbean, 6.3 percent in North America and
Europe, and 2.6 percent in Asia. Estimates in another systematic review were higher,
with similarly wide regional variation: 26 percent in Africa, 13 percent in North
America and Europe, and 8 percent in Latin America and Asia.6 The prevalence of
PPH with 1000 mL blood loss or more was considerably lower in both reviews with
overall estimates of 1.9 to 2.8 percent. Despite lower estimates for PPH in developed
countries compared with developing nations, several studies have noted an increase
in PPH in high-resource regions. In the United States, the prevalence of PPH rose
from 2.3 percent in 1994 to 2.9 percent in 2006, a 26 percent increase. Factors
underlying the increase remain unknown; however, studies investigating changes in
maternal age, obesity, mode of birth, multiple births, duration and characteristics of
labor, and placental abnormalities among other factors found that these putative
observed risk factors did not account for rising PPH rates.
In 2012, World Health Organization published 32 recommendations for the
prevention and treatment of postpartum hemorrhaged. These recommendations were
developed according to the WHO guideline development standards, including
synthesis of available research evidence, use of the GRADE methodology, and
formulation of recommendations by a guideline panel of international experts, which
convened in March 2012.

Conclusion:
All the obstetrics patients undergoing Elective Lower Segment Caesarian Section
tend to lose blood after procedure and more likely to develop primary PPH during
first hour after procedure. To prevent primary PPH we need to monitor these patient
100% during first hour after procedure in recovery room.
 Documentation code:
Apollo Hospitals - AP/CQI.7/CAR/01
Visakhapatnam
Prepared date: December
Clinical Audit Report 16/12/2021

Reference: CQI.7.NABH Standards – Submitted date:

th 21/01/2022
5 Edition

Action Plan:
Action Action Person Next
Recommendation Monitoring
Required by Date Responsible Audit
Adequate
Monitoring of
Patient history
Prompt and early Maternal
and complete
recognition for the 20th Dec Obstetric mortality rate June
coagulation
possibility of 2021 Team by 2022
profile should
PPH. Obstetric
be done prior
Team
to surgery.
Awareness of the Conducting
severity of PPH virtual classes 20th Dec Obstetric Obstetric June
and its and 2021 Team Team 2022
consequences workshops.
Administration
of uterotonic
Monitoring of
Active soon after the Attending
Maternal
management of delivery of the 20th Dec Obstetrician June
mortality rate
the third stage of anterior 2021 and Sister in 2022
by Obstetric
labour. shoulder, charge
Team
controlled cord
traction.
Continuous
Adequate Monitoring of
vitals
Postpartum Maternal
monitoring 20th Dec Sister in June
Observation mortality rate
and watch for 2021 charge 2022
during the first 1 by Obstetric
any signs of
hour after labour. Team
active bleed.
 Documentation code:
Apollo Hospitals - AP/CQI.7/CAR/01
Visakhapatnam
Prepared date: December
Clinical Audit Report 16/12/2021

Reference: CQI.7.NABH Standards – Submitted date:

th 21/01/2022
5 Edition

References:-
 WHO recommendations on prevention and treatment of postpartum
haemorrhage. 2012.
 Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, Gülmezoglu
AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO
systematic analysis.
 Lancet Glob Health. 2014; 2(6):e323-33. Doi: 10.1016/S2214-109X
(14)70227-X.
 WHO recommendations for the prevention of postpartum haemorrhage.
Geneva, World Health Organization,
2007(http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.06_eng.pdf,
accessed 4 May 2009).
 Guideline for the management of post-partum haemorrhage in the community
(version 2.1.1). Birmingham, Good Hope Hospital, NHS Trust, 2005.
 Rath WH. Postpartum hemorrhage--update on problems of definitions and
diagnosis. Acta Obstet Gynecol Scand 2011 May; 90(5):421-8. PMID:
21332452
 Carroli G, Cuesta C, Abalos E, et al. Epidemiology of postpartum
haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynaecol 2008
Dec; 22(6):999-1012.
 Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage:
United States, 1994-2006. Am J Obstet Gynecol 2010 Apr; 202(4):353 e1-6.
 Royal College of Obstetricians and Gynecologists. Prevention and
management of postpartum haemorrhage. RCOG Green-top Guideline No.
52. London: Royal College of Obstetricians and Gynecologists;
2009.Available from http://www.rcog.org.uk/womens-health/clinical-
guidance/prevention-and-management-postpartum- haemorrhage-green-top-
52