CASE STUDY ON POST

PARTUM
HAEMORRHAGE

SUBMITTED TO :
MRs .somibala
SUBMITTED BY :
varsha Sharma
MSc. Nursing first year
1. BIOGRAPHIC DATA

I)

NAME
AGE
SEX
WARD NO.
MRD NO.
MARITAL STATUS
EDUCATION
OCCUPATION
INCOME
RELIGION
LANGUAGE KNOWN
ADDRESS
DIAGNOSIS
DATE OF ADMISSION
DATE OF DISCHARGE
DATE OF CARE STARTED
DATE OF CARE ENDED
INFORMANT

: Mrs.Sangeeta Singh.
: 24years
: Female
: Gynae Ward(F1)
: 897754
: Married
: 10th class
: Housewife
: NIL
:Hindu
: Hindi,urdu
: E-72, Tuglakabad, New Delhi.
: post partum haemorrhage.
: 27-08-2014
: Not yet Discharged
: 23-09-2014
: 27-09-2014
: Self and Husband

INTRODUCTION OF PATIENT

Mrs. Sangeeta singh 24 year old female was admitted with the complaints of leaking per
vaginally and Labour pains since last Night
.
SOCIOECONOMIC BACKGROUND
Mrs.Sangeeta singh lives in a city in her own concrete house. Water and electricity facility is
adequate and her house is well ventilated. Her house has toilet constructed. Her husband is
the earning members of the family. She belongs to the middle class family.
II)

FAMILY HEALTH HISTORY

a) Family composition
S.No
1.
2.

Name

Relationship
to the
patient
Mr. Ravi Singh Husband

Age

Sex

Educatio
n

Occupation

Health
status

26

Male

M.Com.

Good

Mrs. Sangeeta
Singh

24

Female

10th

Private
Business
Housewife

Self

b) Family medical history

Normal

Father is having a history of angiography in 2011and mother is having is a history of

colicystectomy in 2010. Other than this no history of any medical illness and surgical
intervention in the family.
III)

HISTORY OF PRESENT ILLNESS

Present Obstetric History

The client was admitted with the complaints of labour pains and leaking per vaginally since
last night. With 38+4 weeks.
First Trimester: Complaining of mild pain in lower abdomen.
Vomiting, nausea, giddiness
Morning sickness.
Loss of appetite.
Increased frequency of mituration.
Second Trimester: No fresh complaints.
Third Trimester:
Complaining of heart burn.
Constipation.
Increase frequency of mituration.
Pain in lower limbs.
Present Medical History:
No history of any medical illness like TB/DM/HT/prolonged hospitalization.
No history of intake of any medication.
No history of any psychiatric illness.
Present Surgical History
No history of any surgical intervention.
IV)

HISTORY OF PAST ILLNESS

Past obstetrical history

My patient is a primgravida mother. No history of any past obstetric intervention.
History of Past Medical Illness
No history of any medical illness.
History of Past Surgical Illness
There is no significant past surgical history.
V)
PERSONAL HISTORY

1.

Personal habit

: She is non-alcoholic and non-smoker.

2.

Diet

: She is a non-vegetarian

3.

Sleep and rest

4.

Activities of daily living

5.
6.

Elimination
Bladder habits
Hobbies and interest
Marital status
Sexual history
Drug history
Obstetric history

: she usually sleeps 5 hours at night. She has

Difficulty falling asleep.
: little bit difficulty in doing ADL in last
trimester due to gravid uterus.
: bowel habits once a day.
: no problem in bladder habits. She has
increased micturition.
: she spends her free time watching T.V.
: she is married since 2years
: no history of any sexually transmitted disease.
: no history of any drug allergy
: G 1 P0A0 L0(on admission)

Psychiatric history

LMP: 25-12-2013
EDD: 01-10-2014
: no history of any psychiatric illness

7.
8.
9.
10.
11.

12.

VI)

HEAD TO TOE EXAMINATION

General Appearance
Nourishment
Body Built
Hygiene and Grooming

Activity
Posture
Movement

Mental Status Examination

Consciousness
Look
Attitude
Affect and Mood
Speech
Orientation
Vital Signs
Temperature
Pulse
Respiration
Blood Pressure
Weight and Height

: moderately nourished
: Thin
: well groomed and hygiene
maintained
: perform ADL without assistance
: normal posture
: normal movements

:conscious
: anxious
: cooperative
: appropriate
: clear and relevant
:oriented to time, place and
Person
: 98.8F
: 86/min
: 22/min
: 122/84 mm of Hg.

Head

Height
Weight
BMI

: 145 cm
: 51 kg
: 24.28 kg/m2

Shape
Scalp
Face
Subjective Symptoms

: Normal cephalic
:clear.
: no swelling
: no complaints

Texture
Colour
Grooming
Subjective feelings

: Normal
: Black
: Groomed
: No complaints

Eyebrow
Eyelids
Eyelashes
Pupil color
Size
Reaction to light
Corneal reflex
Conjunctiva
Lens
Pupil vision
Extraocculor muscles
Subjective symptoms

: normal and symmetrical

: normal
: equally distributed
: black
: 3 mm
:reactive to light.
: present
: slightly yellowish in colour.
: transparent
: normal
: normal
: no complaints

Position
Cerumen
Otorrhoea
Subjective complaints
Response to normal voice tone
Watch tick test
Subjective symptoms

: normal
: present
: absent
: no complaints of Hearing
: normal voice tone audible
: watch tick heard in both ears
: no complaints

External
Nasal septum
Patency of nasal cavity

: symmetrical no discharge
: midline
: air moves in freely as client
breaths through nares
: normal

Hair

Eyes

Ear

Nose

Frontal and Maxillary Sinuses

 Olfaction
Subjective symptom
Mouth and Larynx
Outer lips
Inner lips
Teeth

Gums
Tongue

: normal
: no complaints.
: pink and moist
: pink, moist and smooth
: all 32 teeth. Teeth are stained
with no dental caries
: brown colour and healthy
: central position, slight white in
Colour.
: normal movement
: dark coloured.
: normal
: not palpable
: no foul smell
: gag reflex present
: no complaints

Movement
Palate
Uvula
Tonsils
Odour of mouth
Pharynx
Subjective data
Neck
Movement
: range of motion normal
Trachea
: midline
Lymph nodes
: not palpable
Jugular vein
: not distended
Carotid pulse
: palpable
Thyroid gland
: normal
Chest
Transverse diameter is twice the anterior posterior diameter and Symmetrical
Expansion of chest
: symmetrical Palpation
Tactile fremitus
: symmetrical Auscultation
Apical pulse
: 84 / min
Breath sounds
: normal vesicular sounds
Cough
: absent
Sputum
: absent
Heart
: S1 S2 sounds are heard
Subjective symptom
: no complaint
Breast and axilla
Symmetry
: symmetrical
Areola and nipples
: color dark brown and normal
Hair distribution
: scanty
Discharge
: absent
Lesions and masses
: absent
Axillary nodes
: not palpable
Condition of breast
: secretory
Abdomen

Appetite

: normal

Skin

Subjective symptoms

: pain present

Color
Texture
Temperature
Lesions
Turgor
Discoloration

: brown
: dry
: warm
: absent
: normal
: absent

Upper Extremities
Symmetry
range of motion
peripheral pulse

reflexes

edema/swelling
cyanosis
joints
deformity

Lower Extremities
symmetry
nails
range of motion
peripheral pulse

reflexes

edema/ swelling
cyanosis
joints
deformities
subjective symptom

Nails

shape
texture
nail bed colour
tissue surrounding nails
capillary refill

: symmetrical
: possible
: brachial and radial pulse
Palpable
: biceps and triceps reflexes
Normal
: absent
: absent
: normal
: absent
: symmetrical
: capillary refill 2 sec
: normal
: dorsalispedis, posterior tibial
and popliteal pulses palpable
: patellar and ankle jerk present
and plantar reflex absent
: absent
: absent
: normal
: no deformities
: pain in both legs
: convex shaped
: smooth
: pink
: intact epidermis and dark
coloured
: 2sec

Genitals and rectum

hemorrhoids
vaginal discharge
labia majora and minora

: absent
: absent
: normal

INVESTIGATIONS DONE IN PATIENT

SNO

TEST NAME

RESULT

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

HAEMATOLOGY
Haemoglobin
Total leukocyte count
Neutrophils
Lymphocytes
Eosinophils
Monocytes
RBC
Haematocrit
Platelet count
Mean corpuscle volume(MCV)
Mean corpuscle haemoglobin (MCH)

8.9gm/dl
11400/cumm
74%
22%
02%
02%
3.64mill/cumm
28.9%
2.79lacs/cumm
77.4fl
24.5 pg

URINE EXAMINATION
1.
2.

Quantity
Colour

30Ml
Pale Yellow

CHEMICAL EXAMINATION
1.
2.
3.
4.

Transparency
Reaction
Sugar
Albumin

Clear
Acidic
Nil
Nil

1.
2.
3.
4.
5.

MICROSCOPIC EXAMINATION
Pus cells
RBCS
Casts
Crystals
Epithelial cells

2-4/HPF
Nil
Nil
Nil
2-4/HPF

BIOCHEMISTRY
1.

Glycosylated Haemoglobin (HbAlc)

5.1%

NORMAL RANGE
13-18gm/dl
4000-11000
45-70
20-45
1- 6
2-10
4.5-5.4
40-54
1.5-4
83-100
27-32

Poor control
Fair control
Good control
Excellent control
Near normal glycemia
Non diabetic level
INTRODUCTION.

>10%
9-10%
8-9%
7-8%
6-7%
<6%

Although postpartum hemorrhage (PPH) has declined in frequency as a cause of maternal

death, it remains a significant cause of maternal morbidity and mortality. Postpartum
hemorrhagic complications (including ruptured uterus) account for 610.5% of nonabortive
maternal deaths in the United States.In developing countries, maternal death rates from
hemorrhage are even higher. Because PPH is one of the more common and, usually, easily
treated complications of delivery, the obstetrician may be lulled into underestimating the
volume and impact of PPH until a catastrophic situation has developed. PPH is best managed
by a high level of awareness of the causes of hemorrhage and a systematic approach to
management when this problem develops.
DEFINITION
Haemorrhage after childbirth, or postpartum haemorrhage (PPH), is the loss of blood
following childbirth resulting in hypovolemia or otherwise causing a woman to become
symptomatic due to the blood loss. Some practitioners measure PPH by a blood loss of
greater than 500 ml of blood following vaginal birth, or 1000 ml of blood following
caesarean section. It is one of the most common causes of prenatal maternal death in the
developing world and is a major cause of maternal morbidity worldwide.
INCIDENCE
Methods of measuring blood loss associated with childbirth vary, complicating comparison of
prevalence rates.A systematic review reported the highest rates of PPH in Africa (27.5%), and
the lowest in Oceania (7.2%), with an overall rate globally of 10.8%. The rate in both Europe
and North America was around 13%.The rate is higher for multiple pregnancies (32.4%
compared with 10.6% for singletons), and for first-time mothers (12.9% compared with
10.0% for women in subsequent pregnancies).The overall rate of severe PPH (>1000 ml) was
much lower at an overall rate of 2.8%, again with the highest rate in Africa (5.1%)
ETIOLOGY:BOOK PICTURE
1.UTERINE ATONY: Over distension of uterus
Induction of labour
Prolonged / precipitate labour
Anesthesia (halogenated) & analgesia
Tocolytics (Tocolytics (also called anti-contraction

PATIENT PICTURE
In my patient uterine atony is
the cause of post partum
haemorrhage.

medications or labour represents) are medications

used to suppress premature labour )
APH
Grand multiparty
Mismanagement of 3rd stage of Labour
Full bladder

2. RETAINED PLACENTA
Simple adhesion
Morbid adhesion>Accreta, Increta & Percreta

Absent in my patient.

3.TRAUMATIC
1. large episiotomy & extensions
2. Tears & lacerations of perineum, vagina or cervix
3. Hematoma
4. Uterine rupture

Large episiotomy and

extensions present.

4.COAGULATION DISORDERS
Abruptio placentae.
Sepsis :IUD,PROM(premature rupture of
membrane)
Massive blood loss
Massive blood transfusion
Severe PET (Pre-eclamptic Toxemia)/ Eclampsia
Amniotic fluid embolism
Hepatitis

My patients blood values are

below normal range.

SYMPTOMS AND SIGNS:

BOOK PICTURE

Uncontrolled bleeding

Decreased blood pressure

Increased heart rate
Decrease in the red blood cell count
(hematocrit)
Swelling and pain in tissues in the
vaginal and perineal area, if bleeding is
due to a hematoma
DIAGNOSTIC EVALUATION:

BOOK PICTURE
HISTORY
GENERAL EXAMINATION
ABDOMINAL EXAMINATION

PATIENT PICTURE
Present
Present
Present
Present
Absent

PATIENT PICTURE
Present
Present
Present

INTERNAL EXAMINATION
HAEMATOLOGICAL EXAMINATION
URINE EXAMINATION
ULTRASONOGRAPHY

Present
Present
Present
Present

MANAGEMENT:-

BOOK PICTURE

PATIENT PICTURE
PREVENTION:
All preventive measures
Regular ANC
are taken to prevent
Correction of anaemia
PPH .
Identification of high risk cases
History of 5 antenatal
Delivery in hospital with facility for Emergency
checkup.
Obstetric Care.
Proper management of 3
Otherwise transport to the nearest such hospital at the
rd stage of labour done.
earliest.
Keep speedy transport available
Local / Regional anaesthesia
ACTIVE MANAGEMENT OF 3RD STAGE OF
LABOUR
4th Stage of labour - Observation, Oxytocin
ACTIVE MANAGEMENT OF 3RD STAGE OF
LABOUR : Oxytocin 20 unit given
Oxytocics - Routine use in third stage blood loss
with 500 ml RL
Tab misoprostol 800 per
by 30-40%
10 Units Oxytocin IM
rectally given .
Syntometrine 1 Amp IV
Placenta removed by
Ergometrine 1 Amp IV
control cord traction .
Carboprost ( better than Ergometrine) 0.125
0.25 Mg IM
Early cord clamping
Controlled cord traction
Inspection of placenta & lower genital tract

Pharmacological management
S.NO

NAME OF THE DRUG

3.
4.
5.

Tab Calcium
Tab. Ferrium
Tab. Pantoperozole

ROUTE, DOSE AND

FREQUENCY
1OD
1 HS
40Mg

ACTION
Calcium supplement.
Iron supplement
H2receptor antagonist

6.
7.
8.

Tab. Limcee
Tab. Crocin Advance
Tab misoprstol 1000 ucg

1 OD
SOS
stat

Vitamin C supplement
Antipyretic
To increase uterine
contraction .

NURSING MANAGEMENT
NURSING DIAGNOSIS:1. Pain in abdomen and pereanal area related to episiotomy wound.
2. Self care deficit related to the pain over the episiotomy site.
3. Altered nutrition less than body requirement related to the losses during pregnancy and
improper diet intake.

4. Risk for infection related to the episiotomy wound.

5. Altered sleep pattern related to the hospital environment.
6. Knowledge deficit related to the baby care and postnatal care .
HEALTH EDUCATION
Monitoring for vaginal bleeding .
Perineal care

Wasing parineal area before and after bowel and bladder movement .
Frequently changing of pads .
Sitz bath with luke warm water .
Use of cotton undergarments.

Diet

Nutritional intake is an important factor in the maintenance of maternal health during

pregnancy and in the provision of adequate nutrients for embryonic/fetal
development.
Assessing nutritional status and providing nutritional information or referral to a
dietician are part of the nurses responsibilities in prenatal care.
Dietary extremes are associated with risks in pregnancy.
Obesity is associated with gestational diabetes, hypertension and monitoring
difficulties.
Malnutrition is associated with maternal anemia and fetal growth restriction, while
deficiency of certain vitamins predispose to congenital abnormalities, folic acid
deficiency is linked to the risk of neural tube defects (NTDs).
A balanced diet rich in fresh fruit and vegetable is recommended. It is prudent to
avoid unpasteurized milk and cheeses and pts.
Pregnant woman should avoid eating liver due to its high vitamin A content.

Vegans should have Iron and vitamin supplementation and ethnic groups lacking
sunlight are advised to have extra vitamin D.
A balanced and adequate diet is of utmost importance during pregnancy and lactation
to meet the increased needs of the mother, and to prevent nutritional stress.
If maternal stores of iron are poor as may happen after repeated pregnancies and if
adequate iron is not available to the mother during pregnancy, it is possible that the
fetus will lay down insufficient iron stores.
About eight midday meals should be advised. Constipation should be avoided by
regular intake of green leafy vegetables, fruits and extra fluid. . Drinking glass of
warm water on getting up each morning and drinking plenty of fluids during the day
can encourage this. Plenty of roughage in the diet is also helpful. Purgatives such as
castor oil to relieve constipation should be avoided. Light household work should be
encouraged but manual physical labour during pregnancy may adversely affect the
fetus.

1. PERSONAL HYGIENE
Advice regarding personal hygiene is equally important.
During pregnancy sweet glands become more active so advice for bathing at least
once a day, preferably twice but clean clothes should be used daily.
The need to bath everyday and to wear clean clothes should be explained.
The hair should also be kept clean and tidy.
2.

REST AND SLEEP

A pregnant woman needs sufficient rest.
She should do less and lighter work.
She must have 8-10 hours of sleep every night.
She needs to take short nap during the day.
As the pregnancy advances, the mother requires more frequent short rests during the
day.
She should avoid strenuous work, carrying heavy loads or weights e.g. bringing water
from long distance, drawing of water from a well etc.
Rest is important for the maintenance of good health.
She should need adequate rest and relaxation.
Relaxation of the mind produces relaxation of the muscle and a relaxed lower uterine
segment and pelvic floor makes it easier for the baby to be born.

3. PHYSICAL WORK
A job provides satisfaction, self esteem and confidence, along with financial peace of mind.
Women can continue working in pregnancy as long as they wish and as long as they and their
baby remain well.
Avoidance of exposure to hazardous chemicals, Smokey environments, excessive lifting and
exercise and at least an 8- hour rest at night is recommended.
4. EXERCISE
Exercise in pregnancy should be encouraged; through with advancing gestation
physical constraints may limit sporting activities.

Exercise can improve cardiovascular function, lower blood pressure and improve
self- esteem and confidence.
Consider decreasing weight bearing exercises like jogging, running and
concentration non weight bearing activities such as swimming, cycling or stretching.
Advise her to avoid risky activities such as surfing, mountain climbing and skydiving.
Limit activity to shorter intervals.
Exercise for 10 to 15 minutes; rest for 2 to 3 minutes, then exercise for another 10 to
15 minutes. The exercise should be decrease as the pregnancy progresses
.

5. COMFORTABLE CLOTHING AND SHOES

It is advisable to wear loose and comfortable cotton clothes, not too tight such as
blouse.
Brassier which supports the breasts should be advised, but must not be too tight so as
to flatten the nipples but lift the breast well.
A support for the abdomen is sometimes required, especially in a multigravida who
has pendulous abdomen so the pregnant mother should advise to support her whole
abdomen with a light belt.
Pregnant should avoid high heeled shoes. She should wear flat shoes to maintain
centre of balance and to prevent backache to some extent.
6. SMOKING
It should be strongly discouraged in pregnancy.
The target should be cessation of smoking, but if not possible, then cutting down to as
few as possible is advisable.
Smokers (especially those smoking > 20/day) have a slightly higher incidence of
miscarriage, a slightly higher perinatal death rate (20% increase in 20/day smokers,
and35% increase if > 20/day) and babies of smokers are 150 to 300 gm lighter than
babies of non smokers.
Furthermore, smoking is associated with a three-fold increase in risk of cleft palate.
Smoking during pregnancy, however, doesnt affect long term mental or motor
development.
7. ALCOHOL
An expectant mother should be advised to avoid drinking alcohol as drinking alcohol
is injurious to the fetus and also to her own health.
It leads to low birth weight and retardation.
Pregnant women are advised to limit alcohol consumption and a consumption 20
gm/week (2 units) appears to be generally safe.
Heavy alcohol consumption (greater than12 units or 120 gm/ day) is associated with
the development of fetal alcohol syndrome. The syndrome is characterized by growth
retardation, neurological and structural defects (facial, cardiac, joints). A lesser degree
of alcohol consumption but still greater than 8 units/day may also be associated with
fetal alcohol syndrome as well as other associated features such as increased risk of
miscarriage and reduced head circumference.
8. BREAST CARE
The mother should advice to clean her breast during bath.

If the nipples are anatomically normal, nothing is to be done beyond ordinary

cleanliness, but if nipples are retracted, correction should be done.
For this mother is taught about nipple care.
She should wash her breast, with soap and water.
To toughen the nipples, it should be massaged by using soap and water and then roll
them between the forefinger and thumb and draw them out everyday during the last
two months. This should be done three times a day.
After massage, the nipples should be dried and an oily substance applied to make
them supple. Advise mother to wear a well fitting and supportive brassiere.

9. DRUGS
The mother should be advised not to take any medicine unless it is prescribed by the
doctor.
As far as possible, medicine should be avoided for the three months unless very
essential.
The mother must inform to the doctor about pregnancy when seeking any treatment
from the doctor or health personnel.
The use of drugs that are not absolutely essential should be discouraged.
Certain drugs taken by the mother during pregnancy may affect the fetus adversely
and cause fetal malformations. The classical example is thalidomide, a hypotonic
drug, which cause deformed hands and feet of the babies born. Streptomycin which
may cause 8th nerve damage and deafness in the fetus, iodine- containing preparations
which may cause congenital goiter in the fetus. Corticosteroids may impair fetal
growth, sex hormones may produce virilism, and tetracycline may affect the growth
of bones and enamel formation of teeth. Anaesthetic agents including pethidine
administered during labour can have depressant effort on the baby and delay the onset
of effective respiration. Later still in the puerperium, if the mother is breast- feeding,
there are certain drugs which are excreted in breast milk.
A great deal of caution is required in the drug intake by pregnant women.
10. PROTECTIONS FROM INFECTIONS AND ILLNESSES
Infections in pregnancy are responsible for significant morbidity and mortality.
Some consequences of maternal infection last a life time.
Education and counseling are important aspects of care for the prevention of maternal
infections. Adolescents mothers are at high risks because of earlier partners.
An expectant mother must be instructed to protect herself from the risk of any
infection especially measles, German measles and syphilis because these infections
can cause spontaneous abortion, malformation, mental retardations, still-birth,
perinatal death etc.
The child may develop congenital syphilis. If the mother is found having syphilis she
must get herself treated by the trained health personnel especially from health
center/hospital.
11. SEXUAL ACTIVITIES
The mother should be advised to avoid coitus during the first three months and the
last two months.
In the first three months it increases the risk of abortion.
The risk of abortion is more in mothers who have previous history of abortion. In late
pregnancy it predisposes to infection.

12. TRAVEL
The mother should be instructed to avoid travel during the first three and last two
months of pregnancy especially long and tedious journey.
If traveling for long distances, periods of activity and rest should be scheduled. While
sitting, the woman can practice deep breathing, foot circling, and alternating
contracting and relaxing different muscle groups. Fatigue should be avoided.

13. REPORTING OF UNTOWARDS SIGNS AND SYMPTOMS

The expectant woman must be instructed to report to health personnel the following signs and
symptoms.

Unusual pain, bleeding from vagina.

Swelling in the feet, hands or face
Headache, dizziness, blurred vision at times. These symptoms indicate the onset of
high blood pressure which is very dangerous and can prove fatal if timely care is not
given.
High fever
Babys movements not being felt.
Any other sigh or symptom which is considered unusual.

14. FAMILY PLANNING

Family planning is related to every phase of the maternity cycle. Educational and
motivational efforts must be initiated during the antenatal period. If the mother has had two
or more children, she should be motivated for puerperal sterilization. The mother should be
educated and motivated for small family norm and spacing of children.
SUMMARY:Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or
cesarean delivery. It is a major cause of maternal morbidity, and one of the top three causes of
maternal mortality in both high and low per capita income countries, although the absolute
risk of death from PPH is much lower in high income countries (1 in 100,000 deliveries in the
United Kingdom versus 1 in 1000 deliveries in the developing world). Hemorrhage is the
most common reason postpartum women are admitted to intensive care units and arguably the
most preventable cause of maternal mortality. Timely, accurate diagnosis is important to
initiate appropriate interventions (eg, drugs, surgery, referral) and improve outcome
CONCLUSION:Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. All women who
carry a pregnancy beyond 20 weeks gestation are at risk for PPH and its sequelae. Although
maternal mortality rates have declined greatly in the developed world, PPH remains a leading
cause of maternal mortality elsewhere.Postpartum hemorrhage. Maternal morbidity by
subregion, 1995. The direct pregnancy-related maternal mortality rate in the United States is
approximately 7-10 women per 100,000 live births.

BIBLIOGRAPHY:1. Dutta .D.C. Textbook of Gynaecology. Sixth Edition.2013. Calcutta. Pp 410-421

2. http://en.wikipedia.org
3. www.medscape.org
4. www.scribd.com
5. Jacob Annamma. A Comprehensive Textbook Of Midwifery. Jaypee publications. Second
edition. New Delhi. Pg 336-345.