EOC Guidebook

VISION

All women enjoy pregnancy and its

outcome with equity, respect,

dignity, and social justice through

better access to quality health

services especially during

pregnancy, child birth and the post

partum.
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Phases of labour

Phase Features Time

duration
Latent Phase Onset of labour pains to dilatation of cervix Maximum 8
to 4 cms: Cervix dilates at the rate of 1 cm hours
for every two hours
Active phase 4 cms to full dilatation: Cervix dilates at the 6 hours.
rate of 1cm for every hour
Early Cervix fully dilated, fetal descent continues, 30 minutes –
Expulsive no urge to push 75 minutes
Phase ( WHO
study)

Late expulsive Cervix fully dilated, presenting part of the 2 minutes

phase fetus reaches pelvic floor, mother has the
urge to push

Stages of labour

Phase Definition Time

duration
First Stage Onset of labour pains to full dilatation of 12- 14 hours
cervix

Second Stage Full dilatation of cervix to the delivery of 30 minutes –

the baby 75 minutes
( WHO
study)

Third Stage Delivery of the baby to expulsion of 10-20

placenta minutes
 4

Prolonged labour.

Latent Phase being the onset of regular painful contractions with cervical
dilatation up to 4 cm and should not be longer than 8 hours.

Active Phase being the regular painful contractions with cervical dilatation
of more than 4 cm and should not last longer than 6 hours.

Causes of prolonged labour.

Powers : Poor or uncoordinated uterine action

Passenger : Foetal head too large or position abnormal

Passage : Pelvis abnormal, or tumour or obstruction in pelvis or birth

canal

Birth waiting Home

Birth waiting homes are places where antenatal mothers from remote areas

with identified risk factors or with out risk factors can come and stay till

they get labour pains. The idea is to encourage the mothers to stay in a

facility (Birth waiting home) which is closer to a CEmONC centre so that

mothers who require emergency treatment can be quickly transferred.

If there is no separate room as birth waiting home, a few beds in antenatal

ward can be reserved for the same purpose. If a mother is returned back

they may not come back to the health facility for various reasons.
 5

Comprehensive Emergency Obstetric Care (CEmONC) – Signal functions

1. Administration of parenteral antibiotics

2. Administration of parenteral oxytocic drugs

3. Administration of parenteral anticonvulsants

4. Manual removal of placenta

5. Removal of retained products

6. Assisted vaginal delivery

7. Basic neonatal resuscitation (i.e: with bag and mask)

8. Performing EOC surgeries - Caesarean sections, life saving

laporotomies

9. Performing Blood transfusion

Basic Emergency Obstetric and Newborn Care (BEmONC) comprises of

1-7
 6

KEY TO PARTOGRAPH

Caution

Partograph should be started after checking that there are no

complications of pregnancy which require immediate attention

PATIENT INFORMATION:

Fill out name, gravida, para, hospital number, date and time of

ruptured membranes.

FOETAL HEART RATE:

Record every half an hour. A rate above 160 or less than 120 per

Minute is a sign of foetal distress. A Foetal Heart Rate of above 180 or less

than 100 per minute indicates severe distress.

AMNIOTIC FLUlD

Record the colour of amniotic fluid at every vaginal examination.

I : Membranes Intact

C : Membranes ruptured, Clear fluid.

M : Meconium stained fluid

B : Blood stained fluid.

 7

MOULDING

1. Sutures apposed.

2. Sutures overlapped but reducible.

3. Sutures overlapped and not reducible.

CERVICAL DILATATION

Assessed at every vaginal examination and marked with a X mark

Begin plotting on the partograph at 4 cm.

ALERT LINE:

A line starts at 4 cm of cervical dilatation to the point of expected

full dilatation at the rate of 1 cm per hour.

ACTION LINE

Parallel and four hours to the right of the alert line.

DESCENT OF THE HEAD ASSESSED BY ABDOMINAL PALPATION

Refers to the part of the head (Divided into 5 parts) palpable above

the symphysis pubis recorded as a circle ( o ). Descent of the head should

always be assessed by abdominal examination immediately before doing a

vaginal examination.

HOURS

Refers to the time elapsed since onset of active phase of labour

 8

(Observed or extrapolated).

TIME

Record actual time.

CONTRACTIONS

Chart every half hour: palpate the number of contractions in 10

minutes and their duration in seconds.

< 20 seconds. 20 - 39 seconds. >40 seconds

and more

OXYTOCIN:

Record the amount of oxytocin per volume IV fluids in drops per

minutes every 30 minutes when used.

DRUGS GIVEN
Record any additional drugs given.

PULSE
Record every 30 minutes and mark with a dot.

BLOOD PRESSURE
Record every 4 hours and m ark with arrows.

TEMPERATURE
Record every 2 hours.

PROTEIN. ACETONE AND VOLUME

Record every time urine is passed.
 9

VAGINAL EXAMINATIONS

Vaginal examinations are repeated every four hours (unless

contraindicated) under strictly aseptic conditions. In advanced labour,

particularly in Multipara (in whom the duration of labour is shorter),

women may be assessed more often, especially if a decision on referral is

to be made.
 10

GUIDELINES FOR ACCELARATION OF LABOUR BY USING OXYTOCIN

IN PRIMARY HEALTH CENTRES

*****

Induction of labour and augmentation of labour are performed for

different indications and the methods are the same.

 Induction of labour:

stimulation of the uterus to begin labour

 Augmentation of labour:

stimulating the uterus during labour to increase the frequency, duration

and strength of contractions

The following guidelines are to be followed for augmentation of labour

at PHC level.

CAUTION: INDUCTION OF LABOUR SHOULD NOT BE

ATTEMPTED AT PHC

 Oxytocin drip to be started only after assessment and decision by Medical

Officer after clinical examination.

 Acceleration to be started only in active phase of labour

 Once again rule out CPD before starting Oxytocin drip

 11

INDICATIONS

1. Inadequate uterine contractions for 1 hour after spontaneous rupture of

membranes

2. Inadequate uterine contraction in active phase of labour

3. MRO (with in 2 hours)

4. If membranes are present same should be ruptured before starting

acceleration.

CONTRAINDICATIONS

 CPD/Contracted pelvis

 Fetal Distress

 Third Gravida and above

 Previous CS

 Severe PIH (not in advanced labour)

 Prolonged rupture of membrane (more than 2 hours)

 All abnormal presentations

 Other Medical Diseases (like Heart diseases, Anaemia)

PRE REQUISITES FOR AUGMENTATION OF LABOUR

1. Rule out CPD

2. Cervical dilatation 4 cm. and above

3. Station of the Head- minus 2 or below

4. Membranes absent or recently ruptured

5. Clear liquor
 12

6. No caput or moulding

7. FH 120 to 160 per minute

8. Occipito Anterior Position

9. No evidence of sepsis

Watch for uterine hyper stimulation (more than 5 contractions in 10

minutes, each contraction lasting for more than 40 seconds) and Foetal

Heart irregularities. These parameters should be monitored by partograph.

WHEN TO TRANSFER?

1. No or poor progress of labour (by partograph) after 1 pint of Oxytocin drip.

2. If hypertonic uterine contractions (when contractions are continuous

without relaxation) or Foetal Distress develops, stop and remove Oxytocin

drip. Start plain RL drip and transfer the patient in left lateral position with

Oxygen.

3. When liquor becomes meconium stained.

4. Caput or moulding develops.

 13

HOW TO TRANSFER?

 Always transfer with a plain RL drip.

 Left lateral position

 Should be accompanied by Staff Nurse or ANM.

 Delivery tray to be available

 Emergency drug tray to be available

 Ambu bag – Adult and Baby to be available

Oxytocin Titration – For Primi Gravida

5 Units in 500 ml. of Dextrose or Ringer lactate (1ml. of Oxytocin = 5 Units)

(1 ml. = 16 drops)

Time since Number of Amount of IV Amount of IV Oxytocin Remarks

induction Drops / mt to fluid in ml. / fluid infused concentration
be infused mt. Every 30 milli Units / mt.
mts. (in ml.)
30 minutes 10 drops / mt 0.625 ml / mt 18.75 ml 6 MU At the end of 1
hour out of 500
1 hour 20 drops 1.25 ml 37.5 ml 13 MU ml of Oxytocin
Titrated IV
fluid, 56.25 ml
is given
1 ½ hours 30 drops 1.875 ml 56.25 ml 19 MU At the end of 2
hours out of
2 hours 40 drops 2.5 ml 75 ml 25 MU 500 ml of
Oxytocin
Titrated IV
fluid, 187.5 ml
is given
2 ½ hours 50 drops 3.125 ml / mt 93.75 ml 31 MU At the end of 3
hours out of
3 hours 60 drops 3.75 ml / mt 112.5 ml 38 MU 500 ml of
Oxytocin
Titrated IV
fluid, 393.75
ml is given
3 ½ hours 70 drops 4.375 ml / mt 131.25 ml 44 MU At the end of 3
½ hours out of
500 ml of
Oxytocin
Titrated IV
fluid, 525 ml is
given
 14

Oxytocin Titration – For Multi Gravida

5 Units in 500 ml. of Dextrose or Ringer lactate (0.5 ml. of Oxytocin = 2.5 Units)
(1 ml. = 16 drops)

Time since Number of Amount of IV Amount of IV Oxytocin Remarks

induction Drops / mt to fluid in ml. / fluid infused concentration
be infused mt. Every 30 milli Units / mt.
mts. (in ml.)
30 minutes 20 drops / mt 1.25 ml / mt 37.5 ml 6 MU At the end of
1 hour out of
1 hour 40 drops 2.5 ml 75 ml 13 MU 500 ml of
Oxytocin
Titrated IV
fluid, 112.5 ml
is given
1 ½ hours 60 drops 3.75 ml 112.5 ml 19 MU At the end of
2 hours out of
2 hours 80 drops 5 ml 150 ml 25 MU 500 ml of
Oxytocin
Titrated IV
fluid, 375 ml
is given
2 ½ hours 100 drops 6.25 ml /mt 187.5 ml 31 MU At the end 2
½ hours 563
ml of
Oxytocin
Titrated IV
fluid is given

WARNING
Use oxytocin with great caution as fetal distress can occur from
hyperstimulation and, rarely, uterine rupture can occur. Multiparous women are
at higher risk for uterine rupture.
Carefully observe women receiving oxytocin.

The effective dose of oxytocin varies greatly between women. Cautiously

administer oxytocin in IV fluids (dextrose or RL), gradually increasing the rate of
infusion until good labour is established (three contractions in 10 minutes, each
lasting more than 40 seconds). Maintain this rate until delivery. The uterus
should relax between contractions.

When oxytocin infusion results in a good labour pattern,

maintain the same rate until delivery.
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 Monitor the woman’s pulse, blood pressure and contractions and check
the foetal heart rate.
 Ensure that the woman is on her left side.
 Record the following observations on a partograph every 30 minutes
o Rate of infusion of oxytocin
Note : Changes in arm position may alter the flow rate
o Duration and frequency of contractions
o Fetal heart rate. Listen every 30 minutes, always in between
contractions. If the foetal heart rate is less than 100 beats per
minute, stop the infusion.

Women receiving oxytocin should never be left alone.

If hyper stimulation occurs stop the infusion.

ASSESSMENT OF CERVIX FOR USING OXYTOCIN

Rating
Factor
0 1 2 3

Dilatation ( cm ) closed 1-2 3-4 more than 5

Length of cervix ( cm ) More than 4 3·4 1·2 less than 1

Consistency Firm Average Soft -

Position Posterior Mid Anterior -

Descent by station of head

-3 -2 -1,0 +1+2
(cm from ischial spines)

Descent by abdominal palpation

4/5 3/5 2/5 1/5
(fifths of head palpable)

WARNING: USE OXYTOCIN ONLY WHEN THE SCORE IS 6 OR MORE.

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TIME INTERVAL BETWEEN THE ON SET OF COMPLICATION

AND MATERNAL DEATH

AVERAGE TIME BETWEEN THE

Sl.
COMPLICATION ONSET OF COMPLICATION AND REFERAL LEVEL
No.
DEATH

1 PPH 2 Hours CEmONC Centre

2 APH 12 Hours CEmONC Centre

3 RUPTURE UTERUS 24 Hours CEmONC Centre

4 TOXAEMIA 48 Hours CEmONC Centre

5 OBSTRUCTED LABOUR 36 Hours – 72 Hours CEmONC Centre

SEVERE ANAEMIA WITH

6 2 Hours – 24 Hours CEmONC Centre
CCF

PHC / GH /
7 SEPSIS 6 Days
CEmONC Centre
 17

MATERNAL DEATHS

DEFINITIONS

MATERNAL DEATH

The death of a woman while pregnant or within 42 days of termination of

pregnancy, irrespective of the duration and site of the pregnancy, from any cause

related to or aggravated by the pregnancy or its management but not from

accidental or incidental causes.

DIRECT OBSTETRIC DEATH - those resulting from obstetric complications of

the pregnant state (Pregnancy, Labour and the puerperium), from interventions,

omissions or incorrect treatment or from a chain of events resulting from any of

the above.

INDIRECT OBSTETRIC DEATHS - those resulting from previous existing

disease or disease that developed during pregnancy and that was not due to

direct obstetric causes but was aggravated by the physiological effects of

pregnancy.
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MEASURES OF MATERNAL MORTALITY

Maternal Mortality Ratio (MMR)

Maternal Mortality Ratio represents the obstetric risk associated with each

pregnancy. It is calculated as the number of maternal deaths during a given year

per 100,000 live births during the same period.

Number of maternal deaths to women

(15-49 years)
Maternal Mortality = ----------------------------------------------------- X 100,000
Ratio (MMR) ----
Number of live births to women
(15-49 years)

Maternal Mortality Rate

Maternal Mortality Rate measures both the obstetric risk and the

frequency with women are exposed to this risk. It is calculated as the number of

maternal deaths in a given period per 1000 women of reproductive age (usually

15 - 49 years).

Number of maternal deaths to women

(15-49 years)
Maternal Mortality = --------------------------------------------------------- X 100,000
Rate
(MM_rate) Number of living women
(15-49 years)
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Life Time Risk of Maternal Death

Life time risk of maternal death takes in to account both the probability of

becoming pregnant and the probability of dying as a result of the pregnancy

cumulated across a woman's reproductive years.

Lifetime Risk of Maternal Death = 1 – (1 – MM_rate / 1,00,000)35

Story of Rose Mary

Rose Mary was born as a girl child for illiterate and poor parents

Slatenathan and Selvi at Maniyakkaranpatti, a small village 5 kms away

from Andipatti, 23 years ago.

When Rose Mary was 8 years old she wanted to go to school like some

girls in and around her village. But she was made to take care of her two

younger sisters and one younger brother.

When she was 10, she was sent to Kerala as household servant. She

returned back at the age of 20.

She got married to one Mr.Yesumuthu, 7 years older than her, a farm

labourer of a neighbouring village. An year later she gave birth to a

female child.
 20

Later when her child was 6 months old she became ill due to TB. She

was provided DOTS at an NGO Hospital and was cured.

When her first child was 2 years she became pregnant again. She

consulted the VHN who is staying at the Bodidasanpatti HSC and

received complete AN Care She was examined by the Lady Medical

Officer at RCH Out Reach camp conducted at Maniyakkaranpatti.

On 22.11.2003 Rose Mary developed pains, VHN was called and Rose

Mary delivered an alive healthy female child at her home at 5.30 AM.

20 Days later on 13.12.2003 Rose Mary developed fever, headache and

vomiting. She was admitted at the NGO Hospital. For three days she

received IV fluids. Medical Officer examined the case on 3 rd day and

referred her to Periyakularn GH.

Rose Mary's family did not have money. She was taken back to home.

She was taken to a traditional healer and a 'thayathu' was tied.

Helpless VHN prescribed a few tablets of Co - trimoxazole. Again on the

6th day of her onset of fever she went to a private clinic at Andipatti.
 21

The doctor referred her to Periyakulam GH. Rose Mary was brought

back to home and she died of Puerperal Sepsis on, 22.12.2003 at 1.00 pm

at her home.

Now both the children are taken care of by the grandmother Mrs.Selvi.

20 years old illiterate uncle ( brother of Rose Mary) has vowed to send

both the little girl children to school.

Why did Mrs. Rose Mary die?

 Rose Mary died because of her poor Socio – economic status

 Illitterate.

 Poor.

 Powerless

 Ignorant.

 Rose Mary died because of false beliefs- Rose Mary's family

believed that Periyakulam GH has no 'RASI' because one of their

relative died at Periyakulam GH a few days back.

 Rose Mary died because

 of the inadequate skills of NGO Hospital staff.
 the PHC system did not take proactive role.
 Lack of confidence in the health system in the minds of the
people.
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Suggestions:
 All PHCs should provide Parenteral administration of
antibiotics to women with puerperal sepsis.
 All PHCs should provide the 5 basic emergency obstetric care
services
(1) Parenteral administration of antibiotics.

(2) Parenteral administration of oxytocics.

(3) Parenteral administration of anticonvulsants.

(4) Assisted Vaginal delivery.

(5) Basic neonatal resuscitation

 All BEmONC PHCs should provide the 7 basic emergency

obstetric care services

1.Parenteral administration of antibiotics.

2.Parenteral administration of oxytocics.

3.Parenteral administration of anticonvulsants.

4.Manual removal of retained placenta.

5.Manual removal of retained products.

6.Assisted Vaginal delivery.

7.Basic neonatal resuscitation

 IEC on Postnatal care and danger signs.

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Story of Vanitha
Baby. Vanitha was born to poor, illiterate parents residing at
Kajalnaickenpettai in Thirupathur Health Unit District 26 years ago.
Like every child Vanitha also wanted to go to school, but her dreams
remained as dreams. She was helping her parents in household works
and worked as agricultural labourer in the village fields.

At the age of 18 she was married to Mr. Sekar from a neighbouring

village. Mr.Sekar who did not know to read and write ,was also a
manual agricultural labourer. After marriage, Mrs. Vanitha delivered
three children in successive pregnancies and now they are aged 6
years, 4 years and 2 years.

Now at the age of 26 years she is pregnant for the fourth time. One
day morning along with her mother she came to PHC
Ramanaickenpettai (nearer to Vanitha’s mother’s place) for checkup.
She did not have any AN care records, but informed the Medical
officer that the Village Health Nurse gave two doses of T.T and 100
Iron and Folic Acid tablets.
Mrs. Vanitha was examined by Dr.Sumathi and the following clinical
findings were made.

- Severely anaemic
- Puffiness of face present
- Bilateral pitting pedal edema present
- BP 150/120 mm of Hg.
- Uterus full term
- Foetal Heart Rate – Normal
- Head mobile.
Dr Sumathy explained the condition to Mrs. Vanitha and her mother in
detail and clearly told that she needs immediate hospitalization in a
 24

FRU. Since there was no male member of the family, they returned
home.

On the same day afternoon Mrs. Vanitha developed Labour pains and
convulsions and somehow they reached GH Vaniyambadi at 4.30 PM
by an auto. From the GH Vaniyambadi, Mrs.Vanitha was referred to
GH Vellore at 5.00pm because there was no anaesthetist and
obstettrician at GH Vaniyambadi.

From GH Vaniyambadi, Mrs. Vanitha’s relatives took her to GH

Thirupathur (a distance of 30 Kms) because she had been admitted at
GH Thirupathur 10 days back for fits treatment (During the previous
admission 10 days back Mrs. Vanitha left GH Thirupathur against
Medical advice).

They reached GH Thirupathur by next day morning at 6 AM from there

Mrs. Vanitha was referred to GH Vellore at 6.30AM. Mrs. Vanitha
continued to throw fits and in semiconcious condition.
From GH Thirupathur Mrs.Vanitha was brought to PHC
Ramanaickenpet at 9.30AM. Dr Sumathy examined her and advised
the relatives to immediately admit her at GH Vellore, the Medical
officer mobilised Rs. 500/- with the help of local Panchayat leader and
arranged a private jeep and referred her to GH Vellore along with a
Village Health Nurse, but the relatives took her to GH Vaniyambadi
and was admitted.

Meanwhile a friend of Mr.Sekar , suggested to shift Mrs. Vanitha to her

mother’s home and perform some religious rites to save her.
Mrs.Vanitha was shifted back to Kajalnaicckenpettai and a goat was
sacrificed to god.
 25

At 2.30 PM, Mrs. Vanitha was brought to PHC Ramanaickenpettai

VHN conducted the delivery – A dead born child at 3.30 PM.

Again the relatives were advised to take her to GH Vellore. Now they
agreed to take her to GH Vellore 90Kms from PHC
Ramanaickenpettai. Mrs. Vanitha was admitted at 6 PM and died at
6.05 PM at the casualty.

Questions:
1. In your opinion what is the Medical cause of death?
2. In your opinion what are the social causes of this tragedy?
3. As a PHC Medical officer how do you feel on reading the
real story of Mrs.Vanitha?
4. As a PHC Medical officer what are the actions you propose
to prevent such tragedies in your area?
 26

Story of Alamelu
Alamelu and her Husband Raja lived in a field hut in Poompatti Village,
2 Kilometers from Tholasampatti Primary Health Centre. The village is
at a distance of 8 Kms from Tharamangalam Block Primary Health
Centre and 15 Kms from Omalur Government Hospital.

Married at the age of 16, Alamelu had two surviving female children
from her first three pregnancies, all of which resulted in Live births. All
three pregancies were free of complications throughout the antenatal,
intranatal and postnatal phases. The first delivery was domiciliary,
conducted by an untrained traditional birth attendant. The second and
third were institutional deliveries at the Government hospital in Omalur.

Alamelu became pregnant for the fourth time at the age of 28. She
was under antenatal care with the local HSC, and was treated for
anaemia with therapeutic doses of IFA. After the onset of labour pains
at about 11 a.m on 11.08.96, Alamelu was taken on a motorbike and
admitted to a private nursing home, 15 Kms away from
Tharamangalam. In this nursing home, only a retired maternity
assistant attends to deliveries. For about ten hours after admission,
there was no progress of labour. Alamelu’s husband Raja stated that
his wife was not examined even once by the doctor. After some time,
Alamelu had bleeding PV. Raja shifted her to another private nursing
home. Alamelu was given two sbottles of blood and underwent
surgery. The dead baby was removed and hysterectomy was done.

Raja took the dead baby to Poompatti for funeral and returned with
money around 9.00 a.m on 12.08.96 only to find that Alamelu had died
at 6.00 a.m.
 27

Questions:
1. Why was Alamelu admitted into PHC when her two deliveries had
taken place at Omalur G.H?
2. What policy recommendation would you make concerning
deliveries in private nursing homes / clinics in the light of Alamelu’s
case?
3. How should the VHN and M.O understand the scope of antenatal
care?
 28

Classification of Causes of Maternal Deaths

Maternal death: The death of a woman while pregnant or within 42 days of termination

of pregnancy, irrespective of the duration and site of the pregnancy, from any cause

related to or aggravated by the pregnancy or its management but not from accidental or

incidental causes (WHO).

Maternal Mortality Ratio:

The Maternal Mortality Ratio is the number of maternal deaths per 100,000 live births

per year (WHO).

Direct obstetric deaths

Maternal deaths resulting from obstetric complications of the pregnant state (pregnancy,

labour, and the puerperium), from interventions, omissions or incorrect treatment, or

from a chain of events resulting from any of the above.

A classification of dual causes of maternal death are more useful. It allows for two levels

of causes: an essential level and a specific level. The essential level identifies a minimum

list of causes that can be identified in all settings, whatever the level of sophistication of

the cause of death reporting. The list of specific causes improves the degree of detail

achieved.
 29

Examples: Antepartum haemorrhage following placenta praevia, Postpartum

haemorrhage following prolonged labour, PPH following cervical tear, eclampsia, sepsis

following prior foetal death (WHO).

Indirect obstetric deaths

Maternal deaths resulting from previous existing disease or disease that developed during

pregnancy and that was not due to direct obstetric causes but was aggravated by the

physiological effects of pregnancy.

Indirect maternal deaths are relatively few in number. The classification should list the

causes of importance according to the local epidemiology of diseases. The diseases

representing relatively large proportions should be listed as such rather than hidden in a

broader category.

Examples: Heart diseases, Hepatitis, malaria, TB, AIDS, tetanus (WHO).

Non-obstetric causes

Death of pregnant woman resulting from accidental or incidental causes. (Examples:

Accident, assault, suicide, snake bite, burns).

 30

A. Direct Obstetric Causes

I. Early Pregnancy death (EPD) (First 20 weeks of pregnancy)

(i)Abortions
01.Spontaneous abortion and haemorrhage
02.Spontaneous abortion and sepsis
03.Spontaneous abortion and trauma
04.Induced abortion and haemorrhage
05.Induced abortion and sepsis
06.Induced abortion and trauma
07.Ectopic pregnancy
08.Molar pregnancy
II.Late pregnancy deaths

(i) Ante partum Haemorrhage (After 20 weeks of pregnancy)

09. APH due to placenta praevia.

10. APH due to abruptio placenta
11.APH due to indeterminate causes.

(ii) Obstructed labour/ rupture uterus

12.Antepartum rupture

13.Postpartum rupture

14. Scar rupture

15. Rupture uterus attributed to oxytocin

16. Rupture uterus attributed to misoprostol

 31

(iii) Post partum Haemorrhage (PPH).

(a)Primary PPH (birth to 24 hours of delivery)

17.PPH following uterine atony due to hydramnios

18.PPH following uterine atony due to twins
19.PPH following uterine atony due to prolonged or obstructed labour
20.PPH following uterine atony due to multiparity
21.PPH following retained membranes or placental bits
22. PPH following retained placenta with normal placentation
23.PPH following retained placenta with abnormal
placentation (acreta/increta/percreta)
24.Traumatic PPH following tears in cervix /vagina / perineum
25.PPH following placenta praevia
26.PPH following abruptio placenta
27.DIC
28.PPH following inversion of uterus.
29.PPH following prior foetal death
30.PPH due to undetermined cause

(b) Secondary PPH (abnormal or excessive bleeding which occurs between 24

hours and 6 weeks postpartum)

31.Secondary PPH due to retained placental tissue

32. Secondary PPH due to sepsis
33. Secondary PPH due to undetermined causes.
(iv) Hypertensive disorders of pregnancy
34.Severe Preeclampsia
35. eclampsia.
36.Chronic hypertension with superimposed PIH
37.HELLP syndrome
 32

38.CVA
(v) Sepsis related to pregnancy and child birth
39.Chorioamnionitis.
40.Puerperal Sepsis following normal delivery
41.Puerperal Sepsis following caesarean section
42.Peritonitis

(vi) Complications of anaesthesia

43.Complications following general anaesthesia

44.Complications following spinal anaesthesia
45.Complications following epidural anaesthesia
46.Complications following local anaesthesia

(vi) Surgical complications

47. Surgical complications following caesarean section

48. Surgical complications following emergency hysterectomy
49. Surgical complications following puerperal sterilization
50. Surgical complications following sterilization after MTP*

(vii) Transfusion reactions

51. Transfusion reactions
52. Reactions following IV fluid administration
(viii) Sudden deaths
53. Pulmonary Embolism
54. Amniotic Fluid Embolism
55. Sudden death due to undetermined cause
 33

(ix) Other conditions

56.Peripartum cardiomyopathy
57. Suicide due to puerperal psychosis.
58. Any other direct cause- specify

B. Indirect Obstetric Causes

(i) Heart diseases complicating pregnancy

59. Congenital Heart Disease
60. Rheumatic Heart Disease
61. Complications following valve replacement
62. Chronic hypertension (existing before 20 weeks & pregnancy)
63. Myocardial infarction
64. Dilated cardiomyopathy
65. Undiagnosed heart disease
(ii) Anaemia
66. Anaemia complicating pregnancy
(iii) Endocrine disorders
67. Diabetes mellitus
68. Thyroid disease
69. Other endocrine conditions
(iv) Infectious diseases
70.Meningitis / encephalitis.
71.Maternal tetanus.
72.HIV / AIDS
73.Malaria
74.Typhoid
75.Tuberculosis
76.Tuberculosis and HIV
77. H1N1( swine flu)
78. Other infections
 34

(v) Liver disorders

79. Jaundice due to hepatitis viruses
80.Jaundice due to noninfectious cause
81. Hepatic encephalopathy
(vi) Renal conditions
82. Acute renal failure due to non obstetric cause
83. Chronic renal failure due to non obstetric causes
(vii) Other conditions
84. Bronchial Asthma
85. Epilepsy
86. Intracranial Space occupying lesion
87. Cancer
88. Haematological causes
89. Other causes-specify

III. Non- Obstetric Causes (accidental or incidental causes)

90.Non obstetric surgical cause (appendicitis, pancreatitis, bowel obstruction,

ovarian torsion etc.)
91. Injury due to burns
92. Injury due to assault
93. Injury due to Road Traffic Accident
94. Injury due to other accidents
95. Electric shock
96. Snake Bite
97. Suicide
98. Any other specify

Note:* included here because death is due to complications of sterilization but not due to
abortion.