Non-pneumatic anti-shock garment

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Non-pneumatic anti-shock garment
NASG rocket girl photo.jpg
A woman demonstrating application of a non-pneumatic anti-shock garment
Specialty Emergency medicine

The non-pneumatic anti-shock garment (NASG) is a low-technology first-aid device used to treat hypovolemic shock. Its efficacy for reducing maternal deaths due to obstetrical hemorrhage is being researched. Obstetrical hemorrhage is heavy bleeding of a woman during or shortly after a pregnancy. Current estimates suggest over 300,000 women die from obstetrical hemorrhage every year with 99% of cases occurring in developing countries; [1] many of these deaths are preventable. Many women in resource-poor settings deliver far from health-care facilities. Once hemorrhage has been identified, many women die before reaching or receiving adequate treatment. The NASG can be used to keep women alive until they can get the treatment they need. [2]

Contents

Background

Every year, an estimated 342,900 women die from complications of pregnancy and childbirth, 99% of these deaths occur in developing countries. [1] Worldwide, for every 100,000 live births, about 251 women die. In some industrialized countries such as the U.S, this is 13 deaths for every 100,000 live babies born with American women having a lifetime risk of 1 in 2,100 of dying from childbirth related complications. However, in some countries, such as Afghanistan up to 1,600 women die for every 100,000 live births and women have a 1 in 11 lifetime risk of maternal death. [3]

For every woman who dies, there are 30 women who suffer a disability as a result of pregnancy or childbirth related complications (a maternal morbidity) and 10 who experience a 'near miss mortality' (a life-threatening obstetric complication). [4] Morbidities can be serious, lifelong ailments which compromise a woman's health, productivity, quality of life, family health and ability to participate in community life. If a mother dies after childbirth, the newborn is ten times more likely to die before the age of two, other children are more likely to suffer from decreased nutrition and decreased schooling. Many motherless families find it difficult to survive, often with older children having to drop out of school in order to work to help support the family or being sent to live with a relatives intact family. [5] In addition to this, maternal and newborn deaths are estimated to cost the world $15 billion in lost productivity annually, with maternal health proven to support a country's economic growth and cut poverty. [6] Maternal death and disability is a human rights issue. It also means hardships and loss of productivity for families, communities and nations. This is of such great concern that in 2000, world leaders decided that improving maternal health should be one of the 8 Millennium Development Goals for the international community.

The leading cause of maternal mortality (deaths from pregnancy and childbirth related complications) is obstetric hemorrhage in which a woman bleeds heavily, most often immediately after giving birth. [7] A woman dies every 4 minutes from this kind of complication. A woman can bleed to death in two hours or less, and in rural areas, where hospitals may be days away, this leaves little hope for women suffering from hemorrhage. [8] Also, in areas that have limited resources, clinics and hospitals might not have the staff or supplies needed to save a woman's life. Women die waiting for treatment. [9]

There are some emerging technologies which are currently being researched and implemented that seek to prevent these unnecessary deaths. [10] One of these is the NASG which is a low-technology first-aid device that can be placed around the lower body of a woman who has gone into shock from obstetric bleeding. This garment decreases blood loss, recovers women from shock and keeps them alive while they are traveling to a hospital or awaiting treatment. [11]

History

In the 1900s an inflatable pressure suit was developed by George Crile. [12] It was used to maintain blood pressure during surgery. In the 1940s and after undergoing numerous modifications, the suit was refined for use as an anti-gravity suit (G-suit). Further modification led to its use in the Vietnam War for resuscitating and stabilizing soldiers with traumatic injuries before and during transportation. [13] In the 1970s the G-suit was modified into a half-suit which became known as MAST (Military anti-shock trousers) or PASG (Pneumatic Anti-Shock Garment). [14] During the 1980s the PASG garment became used more and more by emergency rescue services to stabilize patients with shock due to lower body hemorrhage. During the 1990s the PASG was added to the American College of Obstetrics and Gynecology, making it part of the recommended treatment for use by obstetricians and gynecologists in the USA. [15] However, it was removed from the guidelines later and is no longer on the ACOG guidelines.

From the 1970s, NASA/Ames was involved in developing a non-pneumatic version of the anti-shock garment. This was originally used for hemophiliac children, but has since been developed into the garment known as the Non-pneumatic Anti-Shock Garment (NASG). [16]

The non-pneumatic anti-shock garment is now off-patent and produced in several different locations.

The use of the garment for obstetrical hemorrhage in low-resource settings began in 2002 when Dr. Carol Brees and Dr. Paul Hensleigh introduced the garment into a hospital in Pakistan and reported on a case series of its use. [17]

How it works

The non-pneumatic anti-shock garment is a simple neoprene and Velcro device that looks like the bottom half of a wetsuit cut into segments. It can be used to treat shock, resuscitate, stabilize and prevent further bleeding in women with obstetric hemorrhage.

When in shock, the brain, heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs. The NASG reverses shock by returning blood to the heart, lungs and brain. This restores the woman's consciousness, pulse and blood pressure. Additionally, the NASG decreases bleeding from the parts of the body compressed under it.

Mechanisms of action are based upon laws of physics. [18] Recent research has identified that the pressure applied by the NASG serves to significantly increase the resistive index of the internal iliac artery (which is responsible for supplying the majority of blood flow to the uterus via the uterine arteries). [19] Another recent study has shown the NASG to decrease blood flow in the distal aorta. [20]

After a simple training session, anyone can put the garment on a bleeding woman. Once her bleeding is controlled, she can be safely transported to a referral hospital for emergency obstetrical care.

The non-pneumatic anti-shock garment is light, flexible and comfortable for the wearer. It has been designed to allow perineal access so that examinations and vaginal procedures can be performed without it being removed. Upon application a patient's vital signs are often quickly restored and consciousness regained. It is extremely important not to remove the NASG before a woman receives IV fluids, blood and before all vital signs are restored. Early removal can be dangerous and even fatal.

Research and implementation

In Egypt and Nigeria, in separate and combined analyses, findings showed that women treated with the NASG fared much better than women who were not treated with the NASG. Results showed significant reductions in blood loss, rate of emergency hysterectomy and incidence of morbidity and mortality. [2] [21] [22] Analyses examining the use of the NASG on cases of uterine atony, postpartum hemorrhage, and non-atonic etiologies (ante and postpartum) found similar results. [23] [24] [25] Other analyses found that the NASG additionally resulted in a more rapid recovery from shock, [24] [26] helped women overcome treatment delays [27] and had a similarly strong ameliorative effect on women in severe shock. [2]

A combined analysis on 1442 women recently published, examined the effect of the NASG on women with obstetric hemorrhage. [2] Despite being in a worse condition at study entry, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p<0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35–0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08–0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23–0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27–0.77). The number needed to treat (NNT) to prevent either mortality or severe morbidity was 18 (12–36).

Qualitative research in Mexico and Nigeria has examined acceptance of the NASG and found that overall, there were positive reactions to the garment as a relevant technology for saving women's lives. [28] [29] [30]

Research is currently ongoing in Zambia and Zimbabwe to investigate whether the NASG is more successful if implemented at primary health care facilities where hemorrhage is first identified. [31]

In 2012, the World Health Organization included the NASG in its recommendations for the treatment of postpartum hemorrhage. [32]

Related Research Articles

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In developed countries, most deliveries occur in hospitals, while in developing countries most are home births.

<span class="mw-page-title-main">Maternal death</span> Aspect of human reproduction and medicine

Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while she is pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.

<span class="mw-page-title-main">Postpartum period</span> Time period beginning after the birth of a child and extending for about one month

The postpartum period begins after childbirth and is typically considered to last for six weeks. There are three distinct phases of the postnatal period; the acute phase, lasting for six to twelve hours after birth; the subacute phase, lasting six weeks; and the delayed phase, lasting up to six months. During the delayed phase, some changes to the genitourinary system take much longer to resolve and may result in conditions such as urinary incontinence. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during this period.

<span class="mw-page-title-main">Sheehan's syndrome</span> Medical condition

Sheehan's syndrome, also known as postpartum pituitary gland necrosis, occurs when the pituitary gland is damaged due to significant blood loss and hypovolemic shock or stroke, originally described during or after childbirth leading to decreased functioning of the pituitary gland (hypopituitarism). Classically, in the milder partial form, the mother is unable to breastfeed her baby, due to failure of the pituitary to secrete the hormone prolactin, and also has no more periods, because FSH and LH are not secreted. Although postmenopausal, the mother with this milder form of Sheehan's syndrome does not experience hot flushes, because the pituitary fails to secrete FSH. The failure to breastfeed and amenorrhea no more periods, were seen as the syndrome, but we now view Sheehan's as the pituitary failing to secrete 1-5 of the 9 hormones that it normally produces (the anterior lobe of the pituitary produces FSH, LH, prolactin, ACTH ,TSH and GH ; the posterior pituitary produces ADH and Oxytocin, i.e. the pituitary is involved in the regulation of many hormones. It is very important to recognise Sheehan' stroke as, the ACTH deficiency Sheehan's in the presence of the stress of a bacterial infection, such as a urine infection, will result in death of the mother from Addisonian crisis. This gland is located on the under-surface of the brain, the shape of a cherry and the size of a chickpea and sits in a pit or depression of the sphenoid bone known as the sella turcica. The pituitary gland works in conjunction with the hypothalamus, and other endocrine organs to modulate numerous bodily functions including growth, metabolism, menstruation, lactation, and even the "fight-or-flight" response. These endocrine organs,, release hormones in very specific pathways, known as hormonal axes. For example, the release of a hormone in the hypothalamus will target the pituitary to trigger the release thyroid stimulating hormone, and the pituitary's released hormone will target the next organ in the pathway i.e. the thyroid to release thyroxin. Hence, damage to the pituitary gland can have downstream effects on any of the aforementioned bodily functions.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

Obstetrical bleeding is bleeding in pregnancy that occurs before, during, or after childbirth. Bleeding before childbirth is that which occurs after 24 weeks of pregnancy. Bleeding may be vaginal or less commonly into the abdominal cavity. Bleeding which occurs before 24 weeks is known as early pregnancy bleeding.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Chorioamnionitis</span> Medical condition

Chorioamnionitis, also known as amnionitis and intra-amniotic infection (IAI), is inflammation of the fetal membranes, usually due to bacterial infection. In 2015, a National Institute of Child Health and Human Development Workshop expert panel recommended use of the term "triple I" to address the heterogeneity of this disorder. The term triple I refers to intrauterine infection or inflammation or both and is defined by strict diagnostic criteria, but this terminology has not been commonly adopted although the criteria are used.

<span class="mw-page-title-main">Uterine atony</span> Loss of tone in the uterine musculature

Uterine atony is the failure of the uterus to contract adequately following delivery. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation. Therefore, a lack of uterine muscle contraction can lead to an acute hemorrhage, as the vasculature is not being sufficiently compressed. Uterine atony is the most common cause of postpartum hemorrhage, which is an emergency and potential cause of fatality. Across the globe, postpartum hemorrhage is among the top five causes of maternal death. Recognition of the warning signs of uterine atony in the setting of extensive postpartum bleeding should initiate interventions aimed at regaining stable uterine contraction.

<span class="mw-page-title-main">Postpartum bleeding</span> Loss of blood following childbirth

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breathing rate. As more blood is lost, the patient may feel cold, blood pressure may drop, and they may become restless or unconscious. In severe cases circulatory collapse, disseminated intravascular coagulation and death can occur. The condition can occur up to twelve weeks following delivery in the secondary form. The most common cause is poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who already have a low amount of red blood, are Asian, have a larger fetus or more than one fetus, are obese or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, those requiring the use of a vacuum or forceps, and those who have an episiotomy.

Maternal health is the health of people during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant individuals, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems, sometimes resulting in death. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and checking up on the health of individuals who have given birth. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.

A postpartum disorder or puerperal disorder is a disease or condition which presents primarily during the days and weeks after childbirth called the postpartum period. The postpartum period can be divided into three distinct stages: the initial or acute phase, 6–12 hours after childbirth; subacute postpartum period, which lasts two to six weeks, and the delayed postpartum period, which can last up to six months. In the subacute postpartum period, 87% to 94% of women report at least one health problem. Long term health problems are reported by 31% of women.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant humans. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

<span class="mw-page-title-main">Maternal mortality in the United States</span> Overview of maternal mortality in the United States

Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this metric only includes causes related to the pregnancy, and does not include accidental causes. Some sources will define maternal mortality as the death of a woman up to 42 days after the pregnancy has ended, instead of one year. In 1986, the CDC began tracking pregnancy-related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System. According to a 2010–2011 report although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world.

<span class="mw-page-title-main">Emergency childbirth</span>

Emergency childbirth is the precipitous birth of an infant in an unexpected setting. In planned childbirth, mothers choose the location and obstetric team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned childbirth are low. If the birth is imminent, emergency measures may be needed. Emergency services can be contacted for help in some countries.

Uterine balloon tamponade (UBT) is a non-surgical method of treating refractory postpartum hemorrhage. Once postpartum hemorrhage has been identified and medical management given, UBT may be employed to tamponade uterine bleeding without the need to pursue operative intervention. Numerous studies have supported the efficacy of UBT as a means of managing refractory postpartum hemorrhage. The International Federation of Gynecology and Obstetrics (FIGO) and the World Health Organization (WHO) recommend UBT as second-line treatment for severe postpartum hemorrhage.

Black maternal mortality in the United States refers to the disproportionately high rate of maternal death among those who identify as Black or African American women. Maternal death is often linked to both direct obstetric complications and indirect obstetric deaths that exacerbate pre-existing health conditions. In general, the Centers for Disease Control and Prevention defines maternal mortality as a death occurring within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy or its management. In the United States, around 700 women die from pregnancy-related complications per year, with Black women facing a mortality rate nearly three times more than the rate for white women.

Gwyneth Helen Lewis is a British physician who is a professor at University College London. She previously served as National Clinical Director for Maternal Health and Maternity Services for the Department of Health. Lewis helped to write Maternity Matters, a strategy that outlined the future of maternity care in the United Kingdom.

Maternal health outcomes differ significantly between racial groups within the United States. The American College of Obstetricians and Gynecologists describes these disparities in obstetric outcomes as "prevalent and persistent." Black, indigenous, and people of color are disproportionately affected by many of the maternal health outcomes listed as national objectives in the U.S. Department of Health and Human Services's national health objectives program, Healthy People 2030. The American Public Health Association considers maternal mortality to be a human rights issue, also noting the disparate rates of Black maternal death. Race affects maternal health throughout the pregnancy continuum, beginning prior to conception and continuing through pregnancy (antepartum), during labor and childbirth (intrapartum), and after birth (postpartum).

<span class="mw-page-title-main">Hadiza Galadanci</span> Nigerian professor of gynaecology and obstetrics, Bayero University Kano

Hadiza Galadanci is a Nigerian obstetrician and medical academic. The first female obstetrician and professor trained in Kano State, Galadanci is professor of obstetrics and gynaecology at Bayero University, Kano. She is known for her pioneering contributions to improved obstetric outcomes. An advocate for maternal health in Nigeria and globally, Galadanci is the director of the Africa Center of Excellence for Population Health and Policy, a World Bank-supported initiative aimed at advancing healthcare research and policy in Africa.

References

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  16. ↑ Haggerty J. "Anti Shock Garment". 1996
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  18. ↑ Miller, Suellen; Aderinola Ojengbede; Janet Turan; Oladosu Ojengbede; Elizabeth Butrick; Paul Hensleigh (2007). "2007". Current Women's Health Reviews. 3.
  19. ↑ Lester, Felicia; Amy Stenson; Carinne Meyer; Jessica L Morris; Juan Vargas; Suellen Miller (2011). "Impact of the Non-pneumatic Antishock Garment on pelvic blood flow in healthy postpartum women". American Journal of Obstetrics & Gynecology. 204 (5): e1–e5. doi:10.1016/j.ajog.2010.12.054. PMID   21439543.
  20. ↑ Hauswald, Mark; Michael R Williamson; Gillian M Baty; Nancy L Kerr; Victoria L Edgar-Mied (2010). "Use of an improvised pneumatic anti-shock garment and a non-pneumatic anti-shock garment to control pelvic blood flow". International Journal of Emergency Medicine. 3 (3): 173–175. doi:10.1007/s12245-010-0191-y. PMC   2926865 . PMID   21031041.
  21. ↑ Suellen, Miller; Fathalla, MM; Youssif,MM; Turan, J; Camlin,C; Al-Hussaini, TK; Butrick, E; Meyer, C. (2010). "A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt". International Journal of Gynecology and Obstetrics. 109 (1): 20–4. doi:10.1016/j.ijgo.2009.11.016. PMID   20096836. S2CID   7070375.
  22. ↑ Miller, Suellen; Ojengbede, O; Turan, J; Morhason-Bello, IO; Martin, H; Nsima, D. (2009). "A Comparative Study of the Non-pneumatic Anti-Shock Garment (NASG) for the Treatment of Obstetric Hemorrhage in Nigeria". International Journal of Gynecology and Obstetrics. 107 (2): 121–5. doi:10.1016/j.ijgo.2009.06.005. PMID   19628207. S2CID   205259362.
  23. ↑ Mourad-Youssif, Mohammed; Oladosu A Ojengbede; Carinne D Meyer; Mohammad Fathalla; Imran O Morhason-Bello; Hadiza Galadanci; Carol Camlin; David Nsima; Tarek al Hussaini; Elizabeth Butrick; Suellen Miller (1 September 2010). "Can the Non-pneumatic Anti-Shock Garment (NASG) reduce adverse maternal outcomes from postpartum hemorrhage? Evidence from Egypt and Nigeria". Reproductive Health. 7 (24): 24. doi: 10.1186/1742-4755-7-24 . PMC   2942803 . PMID   20809942.
  24. 1 2 Morris, Jessica L; Meyer, C; Fathalla, MF; Youssif, MM; Al-Hussaini, TK; Camlin, C; Miller, S (2011). "Treating Uterine atony with the Anti-Shock garment in Egypt" (PDF). African Journal of Midwifery and Women's Health. 5 (1): 37–42. doi:10.12968/ajmw.2011.5.1.37.
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  26. ↑ Miller, Suellen; Turan, JM; Dau, K; Fathalla, M; Mourad, M; Sutherland, T; Hamza, S.; et al. (2007). "Use of the non-pneumatic anti-shock garment (NASG) to reduce blood loss and time to recovery from shock for women with obstetric haemorrhage in Egypt". Global Public Health. 2 (2): 110–24. doi:10.1080/17441690601012536. PMID   19280394. S2CID   11392183.
  27. ↑ Turan, Janet; Ojengbede, O; Fathalla, M; Mourad-Youssif, M; Morhason-Bello, IO; Nsima, D; Morris, J; Butrick, E; Martin, H; Camlin, C; Miller, S (2011). "Positive Effects of the Non-pneumatic Anti-shock Garment on Delays in Accessing Care for Postpartum and Postabortion Hemorrhage in Egypt and Nigeria". Journal of Women's Health. 20 (1): 91–8. doi:10.1089/jwh.2010.2081. PMC   3052289 . PMID   21190486.
  28. ↑ Berdichevsky, K; Tucker, C; Martinez, A; Miller, S (2010). "Acceptance of a New Technology for Management of Obstetric Hemorrhage: A Qualitative Study from Mexico". Health Care for Women International. 31 (5): 444–57. doi:10.1080/07399330903518491. PMID   20390665. S2CID   27818047.
  29. ↑ Oshinowo, A (2007). Overcoming Delays in Childbirth due to Hemorrhage: A Mixed Methods Study of the Non-pneumatic Anti-shock Garment (NASG) in Nigeria (Thesis). School of Public Health, University of California, Berkeley.
  30. ↑ Liu, L (2009). A mixed methods study of the implementation of two interventions to reduce maternal mortality in Ibadan, Oyo state, Nigeria (Thesis). University of Liverpool.
  31. ↑ "Non-Pneumatic Anti-Shock Garment for Obstetrical Hemorrhage: Zambia and Zimbabwe". 16 January 2015.
  32. ↑ "WHO recommendations for the prevention and treatment of postpartum haemorrhage (2012)" (PDF). Retrieved 21 September 2013.
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