Introduction

The third stage of labor is potentially the most hazardous for the mother because of the risk of postpartum hemorrhage. Defined by the World Health Organization as postpartum blood loss in excess of 500 ml, it is a clinical diagnosis that encompasses excessive blood loss after delivery of the baby from a variety of sites (uterus, cervix, vagina, and perineum). Blood loss during the first 24 h after delivery is known as primary postpartum hemorrhage, while blood loss from 24 h up to 6 weeks after delivery is termed late or secondary postpartum hemorrhage.

This definition implies that any loss smaller than this is within normal limits and therefore can be tolerated without risk. This is certainly not the case in countries where severe anemia is common and where blood loss of as little as 250 ml may constitute a clinical problem. The incidence of postpartum hemorrhage ranges between 5 and 8 per cent where active management policies of labor are practiced, but may be as high as 18 per cent when a 'physiological' approach is the norm. The mainstay strategies for reducing postpartum bleeding include the use of oxytocic drugs, such as oxytocin and Syntometrine, or early clamping of the cord and delivery of the placenta by cord traction. These are collectively termed active management of the third stage.

Postpartum hemorrhage is one of the leading causes of maternal mortality, particularly in less developed countries. It is implicated in one-sixth of maternal deaths worldwide and is the most common reason for blood transfusion after delivery. Within the United Kingdom there are approximately five deaths per year from hemorrhage, representing 6.4 deaths per million maternities. In those parts of the world where blood replacement is not possible due to lack of resources, persistent severe hypotension postpartum leads to considerable morbidity including acute renal failure, partial or total necrosis of the anterior pituitary gland, and other organ system injury such as pancreatitis and acute respiratory distress syndrome.

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Sleep Apnea

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