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A C T A Obstetricia et Gynecologica

A C T A Obstetricia et Gynecologica

A C T A Obstetricia et Gynecologica
A C T A Obstetricia et Gynecologica


Postpartum hemorrhage – update on problems of definitions and diagnosis


Faculty of Medicine, University Hospital RWTH Aachen, Division of Obstetrics and Gynecology, Aachen, Germany

Key words

Postpartum hemorrhage, mortality, measurement of blood loss, definitions, diagnosis


Werner H. Rath, Faculty of Medicine,

University Hospital RWTH Aachen, Wendlingweg 2, D-52074 Aachen, Germany. E-mail:

Conflict of interest

The author has stated explicitly that there are no conflicts of interest in connection with this article. The author alone is responsible for the content and writing of the paper.

Received: 21 January 2011 Accepted: 30 January 2011

DOI: 10.1111/j.1600-0412.2011.01107.x


Maternal mortality due to postpartum hemorrhage (PPH) continues to be one of the most important causes of maternal death worldwide. PPH is a significantly underestimated obstetric problem, primarily because a lack of definition and diag- nosis. The ‘traditional’ definition of primary PPH based on quantification of blood loss has several limitations. Notoriously, blood loss is not measured or is signif- icantly underestimated by visual estimation and there are no generally accepted cut-offs limits for estimated blood loss. A definition based on hematocrit change is not clinically useful in an emergency such as PPH, as a fall in hematocrit postpartum shows poor correlation with acute blood loss. The need for erythrocyte transfusion alone to define PPH is also of limited value, as the practice of blood transfusion varies widely. Definitions based on symptoms of hemodynamic instability are prob- lematic, as they are late signs of depleted blood volume and commencing failure of compensatory mechanisms threatening the mother’s life. There is thus currently no single, satisfactory definition of primary PPH. Proper and timely diagnosis of PPH should above all include accurate estimation of blood loss before vital signs change. Estimation of blood loss by calibrated bags has been shown to be significantly more accurate than visual estimation at vaginal delivery. Careful monitoring of the mother’s vital signs, laboratory tests, in particular coagulation testing, and imme- diate diagnosis of the cause of PPH are important key factors to reduce maternal morbidity and mortality.

Abbreviations PPH, postpartum hemorrhage


An estimated 14 million cases of postpartum hemorrhage (PPH) occur each year worldwide with a case-fatality rate of 1% (1); one woman dies every 4 minutes from PPH (2). Obstetric hemorrhage has been estimated to cause 25% of all maternal deaths and nearly half of postpartum deaths

Statement: An earlier version of this article was published in German under the title “Definition und Diagnostik postpar- taler Blutungen (PPH): Unterschatzte ¨ Probleme!/ Definitions and Diagnosis of Postpartum Haemorrhage (PPH): Underesti- mated Problems!” in Geburtsh Frauenheilk 2010; 70 (1): 36-40; DOI:10.1055/s-0029-1240719. Copyright Georg Thieme Verlag KG. Thieme publishers have kindly given permission to the publi- cation of this revised article in English.

are due to immediate PPH (3). However, a high number of unreported cases must be taken into account, and the ‘true’ incidence of maternal deaths due to PPH is certainly much higher. The absolute risk of death is much lower in high-income countries with an estimated rate of 1:100 000 deliveries as compared to an estimated rate of 1:1 000 in low-income countries (4). A recent WHO analysis of causes of maternal deaths re- ported a wide variation in the incidence of maternal deaths due to obstetric hemorrhage, which is the single most im- portant cause of both maternal mortality and morbidity. In high-income countries, hemorrhage, mainly due to PPH, is responsible for 13.4% of maternal deaths, whereas it accounts for 34 and 30.8% in Africa and Asia, respectively (3). Decreasing the prevalence of severe PPH remains a chal- lenge. Individual risk factors have been demonstrated in 40%


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Postpartum hemorrhage - definitions and diagnosis

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Table 1. Major problems in risk management of primary postpartum hemorrhage (PPH).

Misdiagnosis or delay in diagnosis


Lack of consensus in terms of PPH definition Underestimation of the speed and extent of hemorrhage

Lack of local ease-to-use action plans (protocols) Lack of adequate education and training

Failures in treatment

such as:


inadequate use of oxytocics (or not available)

delay in blood transfusion/coagulation factors (or not available) ignoring the results of basic monitoring inadequate senior input decision-making failures

Deficiences in the organization (systems failure)

such as: lack of staff and appropriate equipment, ineffective teamwork, coordination,

communication and interdisciplinary cooperation

Collated from information from Upadhyay & Scholefield (2008) (14).

of women who develop PPH, but they are poor predictors of the occurrence of PPH (5). Interest has focused on care pro- cedures, as they are potentially amenable to change. Previous studies on maternal deaths have shown that most deaths due to PPH involve delayed and substandard care in the diagnosis and management of blood loss (6,7). Similar findings were drawn from a population-based study of severe non-lethal PPH (8). The prevalence of PPH (defined as 500ml blood loss) and severe PPH (defined as 1 000ml blood loss) is ap- proximately 6 and 1.86% of all deliveries, respectively, with a wide variation across regions of the world (9). Severe hemorrhage is also the most common cause of se- rious maternal morbidity, including adult respiratory dis- tress syndrome, renal failure, coagulopathy, shock, myocar- dial ischemia, hysterectomy, and long-term morbidity such as anemia, which can be a serious clinical problem, especially in low-income countries. Approximately 20 million women worldwide suffer from acute or chronic disability following immediate PPH each year (2). Severe maternal morbidity due to PPH has been estimated at 4.5–6.7/1 000 deliveries (10,11). Interestingly, recently published population-based studies of severe maternal morbidity demonstrate that the rate of PPH and related serious maternal problems has significantly in- creased in some high-income countries (12,13). The major problems in risk management of PPH are shown in Table 1. Delay in diagnosis and treatment of PPH may re- sult from the lack of consensus in terms of its definition and underestimation of blood loss at delivery, failure of adequate management, poor communication, and deficiencies in orga- nization (14). However, even with appropriate management, approximately 3% of vaginal deliveries will followed by severe PPH (15).

Material and methods

Electronic searches were performed in the Medline database using the key word ‘postpartum hemorrhage’ in combination with ‘definitions’, ‘diagnosis’, and ‘measurement of blood loss’. Approximately 2 600 English-language articles from January 1990 to June 2010 were identified using the key word ‘post- partum hemorrhage’. The search was then focused on the other key words outlined above. Case reports were deleted. Studies selected were mainly published in the last 10 years, but frequently referenced and highly regarded older reports were not excluded. Reference lists of articles identified by this strategy were also searched and articles referring to the key words were se- lected. In addition, relevant chapters of textbooks and current guidelines were examined to capture any further information or additional reports not identified in the electronic search. Finally, 125 publications were judged relevant and 56 were included in this overview. The vast majority of studies are cohort studies, case-control studies or case series examining the measurement of blood loss associated with PPH. Thus, the level of evidence based on the classification of the Oxford Centre of Evidence-Based Medicine is mainly II, III, or IV.


Definitions of PPH and related problems

Proper definition of PPH should be standardized, simple, and appropriate for use in everyday obstetrical practice, not only in high- but also low-income countries; it should take into consideration both the volume loss and the clinical con- sequences of such loss. The recorded parameters should be


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easily measurable and reproducible and the ideal definition should facilitate prompt diagnosis and adequate treatment (16). The definition of PPH should also be considered in the light of recent advances in anesthesia, resuscitation therapy, new drugs, active management of the third stage of labor, and improvement in surgical procedures. It is generally accepted to classify PPH as primary (within the first 24 hours of delivery) and secondary (more than 24 hours after delivery but less than 12 weeks). Otherwise there has been no significant change in the definition of PPH over the past 50 years, and there is currently no single, sat- isfactory definition of primary PPH. The most commonly used (‘traditional’) definition that was proposed by theWorld Health Organization in 1990 is ‘any blood loss from the gen- ital tract during delivery above 500ml’ (17). This is a volume that, when left untreated, may be sufficient to cause hemor- rhagic shock and death in some instances (18). Traditionally, PPH following a cesarean section has been defined as blood loss in excess of 1 000ml (19). These definitions are based on quantification of blood loss originated from ‘historical’ studies published in the early 1960s. Using photometric methods or radioactive chromium- tagged red blood cell techniques, the average blood loss was found to be 300–550ml after vaginal delivery (20,21), and 500–1 100ml after a cesarean birth (21,22); 23% of cesarean deliveries were associated with blood loss of between 1 000–1 500ml, and 8% with a loss above 1 500ml (21). Another study showed that up to 16% of vaginal and 30% of operative vaginal deliveries may be associated with blood loss greater than 500ml (23). Using radioisotope dilution techniques, the mean blood loss for first elective cesarean section was found to be 1 290 (±240ml), which is significantly more than the estimated blood loss recorded by most obstetricians (24). Thus, the ‘traditional’ definition of primary PPH is in reality a reflection of the almost universal tendency to under- estimate delivery blood loss. On the other hand, clinical measurements of blood loss have clearly demonstrated that the average blood loss at vagi- nal and cesarean delivery frequently exceeds 500 and 1 000ml, respectively (25). Table 2 gives an overview on currently used definitions of PPH based on quantification of blood loss and the impact of this on various clinical guidelines. While some guidelines acknowledge the ‘traditional’ definition (26,27), others advocate alternative cut-off values for blood loss or a combination of both estimated blood loss and clinical signs of hypovolemic shock (28–30). Many authors have criticized relying on a definition solely based on the amount of blood loss without consideration of clinical signs and symptoms, as this may lead to inconsistency in management (16,31). It is also a matter of debate whether the ‘traditional’ defini- tion is clinically appropriate regarding the amount of blood loss, and whether it should be revised to identify a group of

Table 2. Definitions of postpartum hemorrhage (PPH) based on quan- tification of blood loss and its use in guidelines.

‘Traditional’ definition:

– blood loss > 500 ml following a vaginal delivery (17) – blood loss > 1000 ml following a cesarean section (19)

ACOG 2006 (26): no single, satisfactory definition Australia (ICD10-AM) 2008 (28):

– Blood loss > 500 ml after vaginal delivery and > 750 mL after a caesarean section German Guidelines 2008 (27): see ‘traditional’ definition Austrian Guidelines 2008 (29):

– Blood loss of 500–1000 ml and clinical signs of hypovolemic shock shock or blood loss > 1000 ml

RCOG 2009 (30):

blood loss of 500–1000 ml in the absence of clinical signs of shock major PPH: blood loss >

1000 mL

moderate 1000–2000 mL severe > 2000 mL

women who become ‘ill’ and are at real risk of severe mor- bidity after the hemorrhage (32). Consequently, it has been proposed that it may be better to think of the term ‘major’ or ‘severe’ PPH, using a definition of loss of more than 1 000ml or more than 1 500ml, rather than defining primary PPH as >500ml blood loss (32). However, it should be kept in mind that a blood loss of 1 500ml reflects the point when physio- logical compensatory mechanisms begin to fail. A generally accepted definition of PPH should not neglect the conditions and circumstances in low-income countries, where women are likely to be severely anemic prior to delivery, and to have co-morbidities such as malaria and experience limited access to treatment facilities (33). While healthy women can usually tolerate acute blood loss of up to 1 000ml or more without significant hemodynamic problems (34), this is certainly not the case in severely ane- mic women. Anemia has been estimated to affect half of all pregnant women in the world. In severely anemic women a mere 250ml blood loss might result in the same adverse clin- ical outcome as the loss of a larger volume in women with a normal hemoglobin value (35). The most important limita- tion of definitions based on cut-offs of estimated blood loss is that frequently blood loss is not measured or is significantly underestimated by visual estimation (25). These inaccuracies may lead to a delay in diagnosis and treatment of PPH, re- sulting in preventable adverse outcomes. Visual assessment has been shown to underestimate postpartum blood loss by 33–50% compared to the ‘gold standard’ photospectrometry


Comparing visual estimation with direct measurement of blood loss at vaginal delivery, the incidence of PPH was 5.7 and 27.6%, respectively, which corresponded to an underes- timation of the incidence of PPH with visual estimation by nearly 90% (38). A similar degree of underestimation was reported by Razvi et al. (39). Several authors have confirmed


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medical practitioners’ inaccuracy in estimating blood loss at cesarean deliveries. Some found underestimation to be common, others overestimation, and still others found in- consistencies but without any particular pattern (40–43). A recent study from Dallas (USA) compared visual estimation with calculated blood loss at vaginal and cesarean delivery; calculated blood loss was determined by a modified version of a calculation for pregnancy blood volume. The visual esti- mation was less than half the calculated measurement during operative vaginal births and more than a third in vaginal births associated with third- and fourth-degree lacerations. The tendency to underestimate was greatest with a calcu- lated loss of >1 000ml; for example, of the 90 cesarean de- liveries with calculated blood loss greater than 1 000ml, only 18% of them were correctly estimated (42). The ‘message’ from the majority of studies was that the higher the mea- sured blood loss, the greater the underestimation by visual assessment (36,39,44). Blood loss was found to be overesti- mated at low volumes (<150–250ml). This applies also to blood loss at cesarean section (41). Intraoperative blood loss measured by the alkaline hematin method during elective lower segment cesarean section was approximately 500ml and did not differ significantly from visually estimated blood loss; however, observer error in es- timated blood loss was higher if a measured loss exceeded 600ml (36). This finding was in accordance with a previous study of the accuracy of blood loss estimated by midwives at a simulated birth (45). In daily obstetric practice, hidden loss in linen, swabs, pads and so on, or hidden loss under the drapes at cesarean section, or in a slow, steady trickle, are common reasons for under- estimation. In addition, contamination with amniotic fluid, urine or other fluids may mask the real amount of blood loss. When using an underbuttocks drape with a graduated pouch for measurement and calculating blood loss by direct weigh- ing of all blood-soaked sponges, the amount of contaminant in the pouch ranged between 4 and 81% of the total fluid collected (46). This wide variation in the amount of contam- inant illustrates the major limitations of direct measurement or weighing blood loss.Weight does not discriminate between blood and other types of fluid and gravimetric methods re- quiring the weighing of all materials may take many hours to complete (46). In a recent study, participants were randomized to estimate simulated blood loss in calibrated or noncalibrated delivery drapes, which also contained 100ml of urine and sponges. Visual estimation with noncalibrated drapes underestimated blood loss, with worsening accuracy at large volumes, such as 16% error at 300ml up to 41% at 2 000ml. The cali- brated drape error was <12% at all volumes (47). The total amount of blood loss can also be difficult to assess because of concealed bleeding within the uterine cavity, into the broad ligament, the peritoneal cavity or retroperitoneal space.

Finally, it has been criticized that these definitions do not consider the rapidity of blood loss, which better correlates with hemodynamic changes and has a considerable impact on severe maternal morbidity (16). In attempts to overcome these inconsistencies, postpartum hemorrhage has been de- fined as either a 10% change in hematocrit between admis- sion and the postpartum period or a need for erythrocyte transfusion (48). Nearly 20 years ago, Combs et al. (48) pointed out that a definition of PPH based on hematocrit change has several advantages: it is objective and relatively precise, admission and postpartum hematocrit are routinely and simply deter- mined; hematocrit is a clinically relevant variable often used in decision-making regarding the need for transfusion; and hematocrit change is affected not only by hemorrhage in the delivery room but also by delayed hemorrhage. Postpartum hematocrit change following vaginal delivery has been shown to have a significant negative nonlinear correlation with vi- sually estimated blood loss (49). However, a definition based on hematocrit change is not clinically useful in an emergency such as PPH for several rea- sons: acute blood loss is mostly not reflected by a decrease in hematocrit or hemoglobin concentration for four hours or more, and the peak drop may be appreciated on day 2 or 3 postpartum (50). Thus, rapid blood loss may trigger a medical emergency prior to observation of a fall in hema- tocrit concentration. Previous studies have shown a weak association between measured acute blood loss and decline of postpartum hematocrit or hemoglobin (43,50,51). There- fore, laboratory changes that are not correlated with events that endanger the patient should not be used to define a medical emergency (31). Furthermore, the change in hematocrit depends on the time of testing and the amount of fluid resuscitation previ- ously administered, and could also be affected by prepartum hemoconcentration, e.g. in patients with preeclampsia or de- hydration. Definitions based on the need for erythrocyte transfusion alone are also of limited value as the practice of blood trans- fusion varies widely according to local circumstances and attitudes to transfusion among both patients and physicians. The speed of estimated blood loss, the peripartal drop of hemoglobin, and the number of erythrocyte transfusions have been proposed to define severe PPH (Table 3; 52); how- ever, all definitions are of limited clinical value for the reasons mentioned above. Other authors have suggested abandoning altogether numerical assessments and instead defining PPH as any excessive bleeding resulting in signs and symptoms of blood loss (33). This is the merit of John Bonnar, who characterized the clinical signs and symptoms related to the volume of blood loss (52). As a consequence of increased circulating blood volume during pregnancy, vital signs of hypovolemic shock become


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Table 3. Definitions of severe postpartum hemorrhage (PPH).

transfusion 4units of blood blood loss of 50% of the circulating blood volume in less than three hours blood loss > 150ml/minute within 20 minutes (50% blood volume) peripartal drop of hemoglobin concentration of 40g/l sudden blood loss > 1500ml (25% of the blood volume)

Collated from information from Bonnar (2000) (52).

relatively insensitive in pregnancy. Tachycardia does not usu- ally develop until blood loss exceeds 1 000ml, and blood pressure is usually maintained in the normal range. A blood loss of up to 1 500ml will begin to manifest clinical signs, such as a rise in pulse and respiratory rate, and a slight recordable fall in systolic blood pressure. Systolic blood pressure below 80mmHg usually indicates a blood loss in excess of 1 500ml clinically associated with worsening tachycardia, tachypnea, and alteration of mental status. Definitions based on symptoms of hemodynamic instabil- ity are therefore problematic, as they are late signs of depleted blood volume and commencing failure of compensatory mechanisms. The relative masking of signs during pregnancy hinders early recognition of hypovolemia and delays treat- ment, resulting in further blood loss and increased risk of hemorrhagic shock. Consequently, hypovolemic women who begin to decompensate, as evidenced by hypotension, will de- teriorate extremely rapidly (53). Furthermore, confounding factors such as drug-induced tachycardia, e.g. by oxytocin or nifedipine, or hypovolemia due to antenatal blood loss should be taken into account.

Diagnosis of PPH

Proper and timely diagnosis of PPH may follow the principles shown in Table 4. First, the early recognition of patients at increased risk of PPH prior to delivery is useful, although the assessment of risk factors is of limited predictive value. In ad-

Table 4. Diagnosis of postpartum hemorrhage (PPH) and adverse clinical events.

Timely recognition of patients at increased risk of PPH prior to delivery Proper estimation of blood loss before vital signs change –Accurate visual estimation (teaching tools clinical reconstructions and ‘pictorial’ algorithm (EL lb) (Bose et al. 2006, 53) –Objective measurement of blood loss (such as BRASSS-V blood collection drape with calibrated receptacle): EL lb Close monitoring of the patient’s condition –Use of Early Warning Scores (MEOWS): Mental response, pulse rate, systolic blood pressure, respiratory rate: EL Illc Laboratory tests, especially to recognize coagulopathy in time Clinical diagnosis of PPH-cause at the earliest time to institute adequate treatment (pharmacological and/or surgical treatment)

EL, level of evidence.

dition, proper estimation of blood loss is needed before vital signs change. There is consistent evidence that the accuracy of visual estimation of blood loss can be improved signifi- cantly by simulating clinical scenarios with known measured blood loss or using ‘pictorial’ algorithms as a teaching tool in labor wards (53). Several recent studies have addressed this issue (47,53–55). Interestingly, among professional groups the anesthetists were the most accurate estimators of blood loss, followed by midwives (53). Regular ‘fire drills’ should be organized to train staff in the assessment of blood loss and to test local systems in real time (14). Recent studies have shown that low-cost calibrated plas- tic bags, such as the BRASSS-Vdrape (excellentfixabled@, are useful tools to measure blood loss at vagi- nal delivery before the maternal cardiovascular system dete- riorates (50). Drape estimation of blood loss was found to be 33% more accurate than visual estimation, and use of the drape resulted in a diagnosis of PPH four times as often as the visual estimate (37). The drape-measured blood loss was equally good and as efficient as ‘gold-standard’ spectropho- tometry. Use of the drape has been shown to lead to earlier transfer from rural areas to a higher medical facility (50). The effect of a collector bag for measurement of postpar- tum blood loss after vaginal delivery was recently studied in a cluster randomized trial in 13 European countries (56). Maternity units were randomly assigned to systematic use of a collector bag or to continue to visually assess postpartum blood loss after vaginal delivery. The rate of severe PPH was not significantly different between the groups (1.7 vs. 2.06%). These findings questioned the benefit of collector bag use in reducing the rate of severe PPH at vaginal delivery. How- ever, further research is needed to test the collector bag in connection with other effective management strategies. Laboratory-based methods for measuring blood loss (such as photometric techniques) are not practical for clinical use but may be suitable in research (25). If PPH is suspected, careful surveillance of the mother is mandatory for a timely recognition of impending hemody- namic instability and for early detection of concealed intra- abdominal bleeding, especially after cesarean section. Reflecting on the relation between clinical signs of hem- orrhagic shock and volume of blood loss, as described by Bonnar (52), a classification has been proposed for a more practical approach using an alert- and an action-line (16). A perceived loss of 500–1 000ml in the absence of clinical signs of shock and cardiovascular instability should prompt ba- sic measures of monitoring and ‘readiness for resuscitation’ (alert line), and a perceived loss >1 000ml or a less associated with clinical signs of shock should prompt a full protocol of measures to resuscitate, monitor, and arrest the bleeding (action-line). This classification is in accordance with the recent Royal College of Obstetricians and Gynaecologists’ guideline (30).


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An Early Warning Score modified slightly for obstetric use (MEOWS) is a simple scoring system that can be performed at the patient’s bedside using commonly available clinical parameters for the sick (14). The principle is that smaller changes in all the parameters combined will be noticed earlier than a large change in one parameter alone. For example, a marked drop in blood pressure is usually a late sign of hypovolemia, whereas respiratory rate is one of the most sensitive markers of well being. This warning score system is suitable only for labor wards with sufficient staff, and may be too complex to use in the emergency of an acute PPH, and may also not be proposed for full implementation in areas which are resource-poor. Nevertheless, monitoring of the mother’s vital signs is imperative. Laboratory tests including coagulation testing should be performed, in particular to diagnose life- threatening coagulopathy at the earliest time. Finally, imme- diate diagnosis of the cause of PPH is required for adequate pharmacological and/or surgical treatment.


PPH is a significantly underestimated obstetric problem, pri- marily because of a lack of definition and diagnosis. There is an urgent need to unify commonly used definitions of PPH and to create a definition that is appropriate for both high- and low-income countries. A measured blood loss of 1 000ml may be an appropriate cut-off to define PPH, irrespective of the mode of delivery. For clinical purposes, an adequate defi- nition of PPH should also consider early signs and symptoms of hypovolemia, although it must be kept in mind that in- creased circulating blood volume in pregnancy may mask clinical symptoms of hypovolemic shock. The accurate estimation of blood loss will allow correctly timed and appropriate intervention by warning of impend- ing hypovolemic shock. Visual estimation of blood loss is of limited value, as underestimation is common, but can be improved significantly by simulating clinical scenarios with known measured blood loss or using ‘pictorial’ algorithms as a teaching tool in labor wards. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after birth. The use of calibrated collection bags has proven to be a useful tool for a more accurate measurement of postpartum blood at vaginal deliveries. The most important key factors for a proper and timely diagnosis of PPH are (57):


accurate estimation of blood loss before vital signs change;


careful monitoring of the mother’s vital signs [note

the Modified Obstetric Early Warning Scoring (MOEWS)




coagulation testing, to diagnose impending coagulopathy

early; and

4. immediate diagnosis of the cause to initiate appropriate treatment. This will counteract the development of severe PPH and prevent adverse outcomes.


No specific funding.


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