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presentation
DISSERTATION PROPOSAL
ON

Incidence and Risk Factor of Post Partum

Hemorrhage among the Patients of Hospitals in
Badda Area, Dhaka
Introduction
Globally, postpartum hemorrhage (PPH) is a leading cause of
maternal mortality. The global prevalence of PPH is 6 % and the
highest burden is experienced in low-income countries. The
magnitude of PPH in Bangladesh is high at 10.5 %. In Selected
area a, PPH causes 25 % of all maternal deaths. However, there is
little information on the magnitude and risk factors for PPH.
Common causes of PPH are uterine atony, genital tract injuries,
failure of the blood coagulation system and trauma. Uterine atony
is responsible for the majority (75 %) of PPH.
Background Information
Primary postpartum hemorrhage (PPH) is defined as blood loss
from the genital tract of 500 mL or more following a normal
vaginal delivery (NVD) or 1,000 mL or more following a
cesarean section within 24 hours of birth. PPH contributes
significantly to maternal morbidity and mortality worldwide.
Women can rapidly hemorrhage and die soon after giving birth. It
can be a devastating outcome to many young families. Women
giving birth in low-resource settings are at a higher risk of death
than their counterparts in resource-rich environments.
Justification of the Study
When looking at data sources on the incidence of PPH in high
resource countries, it appears that research in this area needs to
be improved. One review recommended an improvement in data
collection, in particular with regard to measurements of severity.
This work also reported that overall the incidence of PPH was
increasing, especially because of severe PPH from uterine atony.
Atonic PPH is the leading cause of PPH, whatever the mode of
delivery and the severity and its severe forms are often
unexpected and may occur in the absence of recognized risk
factors.
LIST OF VARIABLES
Dependent Variables
The variables retained concerned the characteristics of the
women and the healthcare establishments. At the individual level,
the following variables were considered:
 Maternal age (<19, 20 to 34 and >35 years).
 Preterm premature rupture of membranes, possible premature
delivery .
 Chronic or gestational high blood pressure, GDM, previous
caesarean.
 Prolonged labour, history of uterine scarring, preeclampsia,
chorioamnionitis, mode of delivery, home-to-hospital distance.
Independent Variables
Socio demographic variables:
 Age
 Sex
 Marital status
 Religion
 Educational status
 Occupational status
 Family income
Service related variables-
 Nurse's care
 Doctor's service
 Hospital facilities
Operational Definition
Definition of PPH
Primary PPH (within 24 hours) is typically described as bleeding
500 mL after vaginal birth and 1000 mL after caesarean section
(CS), while severe PPH is bleeding 1000 mL after vaginal birth.
(1,2) However, any amount of blood loss that results in signs and
symptoms of hypovolemic shock or hemodynamic instability
should be considered PPH.
Incidence of PPH
Primary PPH is estimated to occur in 2% to 6% of all births
worldwide. (4,5) Secondary PPH occurs ≥ 24 hours postpartum
and is estimated to occur in 1% to 3% of all births, but actual
incidence is less certain. (6,7)
In Hutton et al.’s study of home births and a matched sample of
hospital births attended by Ontario midwives, PPH was
documented in 2.5% of home and 3.0% of hospital births.
The overall rate of PPH increased from 5.1% to 6.2% in
Canadian hospitals from 2003-2010, driven by a rise in incidence
of atonic PPH. Similar trends have been observed in other high-
resource countries. Researchers have not been able to identify a
clear cause for recent population-level increases in PPH.
Causes and complications of PPH
The path physiology of PPH can be conceptualized by
considering the 4 Ts: tone, tissue, trauma andthrombin. As the
majority of PPH cases are due to uterine atony (70%) this
guideline focuses on this cause. However midwives should
consider other possible causes of abnormal bleeding when
approaching the management of PPH.
Maternal deaths due to PPH are rare in Canada, occurring in
approximately 30/100 000 cases of PPH diagnosed from 1991-
2010. (10,11) Severe adverse outcomes are rare even in cases of
PPH severe enough to warrant blood transfusion.
Risk factors associated with PPH
Researchers have identified numerous antenatal and
intrapartum factors associated with increased risk of PPH. Most
factors are not strongly predictive of PPH and PPH often occurs
in the absence of risk factors. It is not clear how presence of
multiple risk factors affect overall risk of PPH.
Research suggests that home or out-of-hospital birth is
associated with a similar or reduced risk of PPH compared to
hospital birth. Medical interventions that are more likely to occur
in a hospital setting (induction, augmentation, operative delivery)
may explain some of the differences observed between groups.
Research Question
1. What is the level of Incidence and Risk Factor of Post Partum
Hemorrhage among the Patients of Hospitals in Badda Area,
Dhaka ?
Study Objective (s)
To study the incidence and risk factors for postpartum hemorrhage
(PPH) among the Patients of Hospitals in Badda Area.
General Objective
To calculate the average point incidence of PPH in women with in
the selected area
Specific Objective
To detect the incidence, indications, and complications of PPH
over 6 months in A Hospitals in Badda area.
To identify that important public health relevance where severe
PPH is a leading cause of major maternal morbidity
To identify different risk factors for PPH among the Patients of
Hospitals in Badda Area.
Conceptual Framework
Systems-level
interventions

KQ5
KQ5
Interventions
Interventions for
for
acute
acute blood
blood loss
loss
Interventions
Interventions anemia
anemia
Compression
Compression
techniques
techniques
Management
Management of of Medications
Medications
Postpartum
Postpartum Hemorrhage
Hemorrhage Procedures
Procedures KQ4 Final
Intermediated
Intermediated KQ4 Final health
health
(PPH)
(PPH) Women
Women withwith PPH
PPH Surgeries
Surgeries outcomes
outcomes
outcomes outcomes
immediately
immediately post-birth to
post-birth to Mortality
Blood
Blood loss
loss Mortality
12
12 weeks
weeks postpartum
postpartum Uterine
KQ1
KQ1 KQ2
KQ2 Transfusion
Transfusion Uterine
following
following pregnancy
pregnancy of of ≥≥ preservation
ICU
ICU admission
admission preservation
24 weeks gestation
24 weeks gestation future
KQ3
KQ3 Anemia
Anemia future fertility
fertility
Compression
Compression techniques
techniques Breastfeeding
Length
Length of
of stay
stay Breastfeeding
Medications
Medications Psychological
Psychological
Procedures
Procedures Harms Impact
Impact
Surgeries
Surgeries Resolution
Resolution of of
Blood
Blood and
and fluid
fluid products
products anemia
anemia
Anti-shock
Anti-shock garment
garment Harms
Harms of of
treatment
treatment
Review of Literature
We selected potential risk factors for consideration in our analyses.
Pre-pregnancy factors included marital status, ethnicity, uterine
anomalies (septated uterus, uni- or bicornuate uterus, uterus
didelphys), previous uterine surgery (myomectomy and septal
removals), previous cesarean section, previous severe PPH (≥1500
mL), and uterine fibromas. Current pregnancy conditions included
maternal age, ethnicity (country of origin), pre-pregnancy body
mass index (BMI), anemia in start of pregnancy (hemoglobin ≤9
g/dL), assisted reproductive technology (in vitro fertilization [IVF]
or intra-cytoplasmic sperm injection [ICSI]), multiple pregnancy,
gestational diabetes (insulin treated or diet regulated), use of
anticoagulant medications such as low molecular weight heparin
(LMWH) in pregnancy, polyhydramnios, severe preeclampsia or
HELLP-syndrome, and premature rupture of membranes (PROM).
Methods and Materials
Study Design

Between March 2013 and March 2014, a prospective cohort

study was conducted at six health facilities in Bangladesh.
Women were administered a questionnaire to ascertain risk
factors for postpartum hemorrhage, defined as a blood loss of 500
mls or more, and assessed using a calibrated under-buttocks
drape at childbirth. We constructed two separate multivariable
logistic regression models for the variables associated with PPH.
Model 1 included all deliveries (vaginal and cesarean sections).
Model 2 analysis was restricted to vaginal deliveries. In both
models, we adjusted for clustering at facility level.
Study population
The data will be collected from the patients who are admitted in
Gynae & Obs wards of Hospitals in Badda Area.
Study Area
The study place will be selected at Badda area.
Study period
The study will be done within the time period of January to June
2018.
Inclusion Criteria
 All Pregnant women attending ANC unit of the teaching
hospital.
Patients who willingly express their interest to participate in the
study.
Study population
Exclusion Criteria
Research instrument
Sample size
Sampling Technique:
Data Collection procedures
Data presentation:
Data Analysis Plan
Ethical Consideration