SE M I N A R S I N P E R I N A T O L O G Y ] (2015) ]]]]]]

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Seminars in Perinatology

www.seminperinat.com

Obstetric hemorrhage: A global review

Dena Goffman, MDn, Lisa Nathan, MD, MPH, and Cynthia Chazotte, MD
Department of Obstetrics and Gynecology and Womens Health, Monteore Medical Center, Albert Einstein College of
Medicine, 1825 Eastchester Rd, Bronx, NY 10461

article info abstra ct

Keywords: Postpartum hemorrhage remains the number one cause of maternal death globally despite
Obstetric hemorrhage the fact that it is largely a preventable and most often a treatable condition. While the
Postpartum hemorrhage global problem is appreciated, some may not realize that in the United States postpartum
Patient safety bundles hemorrhage is a leading cause of mortality and unfortunately, the incidence is on the rise.
In New York, obstetric hemorrhage is the second leading cause of maternal mortality in the
state. National data suggests that hemorrhage is disproportionally overrepresented as a
contributor to severe maternal morbidity and we suspect as we explore further this will be
true in New York State as well. Given the persistent and signicant contribution to
maternal mortality, it may be useful to analyze the persistence of this largely preventable
cause of death within the framework of the historic Three Delays model of maternal
mortality. The ongoing national and statewide problem with postpartum hemorrhage will
be reviewed in this context of delays in an effort to inform potential solutions.
& 2015 Elsevier Inc. All rights reserved.

Magnitude of the global problem Severe postpartum hemorrhage increasing in the

Postpartum hemorrhage (PPH) remains the number one cause
of maternal death globally despite the fact that it is largely a
preventable and most often a treatable condition. Accounting
for nearly three quarters of all cases of obstetric hemorrhage,
PPH is cited in more than two-thirds of all hemorrhage
related maternal deaths.1 Furthermore, a World Health
Organization multi-country analysis found PPH was the
leading cause of maternal near-miss cases resulting in
signicant organ impairment.2 In all, 99% of cases of PPH
worldwide occur in countries the WHO denes as the devel-
oping regions of the world and 42% of PPH deaths occur in
sub-Saharan Africa alone.1 Regardless of the denition used,
differences by Millennium Development Goal region are quite
remarkable. The lowest prevalence rates of PPH are found in
the countries of Oceania (7.2%) and the highest in the world
are on the continent of Africa (25.7%).3
United States
In the United States, postpartum hemorrhage is the fth
leading cause of mortality, accounting for approximately 11
12% of maternal deaths.4,5 Multiple studies consistently show
the incidence is on the rise in the United States68 as well as
other high resource countries.7,911 Comparative U.S. data
from 1994 to 2006 show a 26% increase in the percentage of
delivery hospitalizations with a code for PPH and a 50% rise
in cases of PPH caused specically by uterine atony.8 Severe
PPH has also shown an increase of 8.9% per year, unrelated
to temporal trends in the known risk factors; advanced
maternal age, grand multiparity, previous cesarean birth,
broids, multiple gestation, polyhydramnios, placenta pre-
via or abruption, and induction of labor.6 This apparent rise
in PPH is underscored further by the fact that for each
woman who dies as a result of PPH, an alarmingly greater

n
Corresponding author.
E-mail address: dgoffman@monteore.org (D. Goffman).

http://dx.doi.org/10.1053/j.semperi.2015.11.014
0146-0005/& 2015 Elsevier Inc. All rights reserved.
2 SE M I N A R S I N
number of women likely suffer related severe maternal
morbidity.
Postpartum hemorrhage is a major preventable
cause of maternal mortality in New York State
The contribution of PPH as a cause of maternal mortality in
New York State is not precisely known. Accurate reporting of
cases of maternal death for the New York State (NYS) has
been difcult especially at the level of cause of mortality.
There are multiple sources of maternal mortality data in NYS:
New York Patient Occurrence and Tracking System
(NYPORTS); Statewide Planning and Research Cooperative
System (SPARCS); American College of Obstetricians &
Gynecologists-NYS Safe Motherhood Initiative (NYS ACOG-
SMI); New York State Department of Health (NYSDOH) vital
statistics data; New York City Department of Health and
Mental Hygiene (NYCDOHMH) enhanced surveillance pro-
gram; and reports from the literature that link more than
one database. All these sources have their inherent limita-
tions. Nonetheless, hemorrhage as a cause of mortality in
NYS may be higher than in other states. NYSDOH (20032005)
data estimate hemorrhage as a cause of death in 15.3%,
compared to 11.3% nationally.4 Of the maternal deaths
reported to the NYS ACOG-SMI for the years 20032005,
15.2% were from hemorrhage. This rate has essentially been
unchanged since, with more recent data from 2007 to 2009
showing a rate of 15.8%.12 The NYCDOHMH report on mater-
nal deaths from 2001 to 2005 reveals even higher statistics.13
This data estimates that hemorrhage accounts for 16.8% of
maternal deaths and is the second leading cause of maternal
mortality in the state. National data suggests that hemor-
rhage is disproportionally overrepresented as a contributor to
severe maternal morbidity14,15 and we suspect as we explore
further this will be true in New York state as well.
Persistence of a preventable cause of mortality
As one of the major contributors to maternal mortality, it
may be useful to analyze the persistence of this largely
preventable cause of death within the framework of the
historic Three Delays model of maternal mortality.16 In this
model, three delays are identied that contribute most
directly to maternal death; a delay in the decision to seek
care, a delay in reaching care, and a delay in receiving quality
care. We see similar delays in reviews of cases of PPH. The
delay in the decision to seek care is a critical element that
begins with recognizing there is a problem. Postpartum
hemorrhage is often missed in its early stages for a multitude
of reasons. One of the complicating factors is the lack of a
standardized denition for PPH. Postpartum hemorrhage has
historically been dened on a global scale by the World
Health Organization as any blood loss from the genital tract
during delivery above 500 mL.17 This is an important de-
nition globally because of the many areas around the world
where signicant anemia is common and seemingly normal
blood loss at delivery can result in severe morbidity from
hemorrhagic shock and even mortality. Another frequently
P E R I N A T O L O G Y ] (2015) ]]]]]]
used denition is a blood loss of 500 mL or greater after vaginal
delivery and 1000 mL or greater after cesarean birth.18 Recently,
the American College of Obstetricians and Gynecologists pub-
lished a nomenclature consensus document which included
the following revised early PPH denition: the cumulative blood
loss of 1000 mL or greater or blood loss accompanied by signs/
symptoms of hypovolemia within 24 h following the birth
process.19 This important revised denition can assist in
identifying those patients whose blood loss may not initially
appear to be signicant in volume, but whose clinical exam
and vital signs indicate severe hypovolemia and the need for
closer supervision and possible interventions. It is important to
capture these patients promptly and accurately, as currently
these patients are often diagnosed at a later stage in the
process when the risks of subsequent hemorrhagic shock,
coagulopathy, infertility, adult respiratory distress syndrome,
and Sheehan syndrome18 are signicantly increased.
Gross underestimation of blood loss and delayed recogni-
tion of clinical signs of hypovolemia during labor, birth, and
the postpartum period are also large contributors to the delay
in the decision to seek care. Experts in the eld consistently
report the likely contribution this has to preventable morbid-
ity and mortality.5,20 Visual estimation of blood loss is the
traditional technique used in obstetrics and can result in
dramatic and dangerous underestimation, particularly when
large volumes are lost.21,22 Strategies have been explored in
attempt to improve clinicians estimation skills, however,
even with improvement noted after training with visual aids,
skill decay became apparent within 9 months.23 Therefore,
techniques to facilitate improved estimation and/or direct
measurement of blood loss are sorely needed. This will be a
critical step in addressing this rst delay since appropriate
management of PPH requires accurate recognition of the
amount of blood lost and an appreciation that blood loss is
cumulative for each patient.24,25
The second delay described by Thaddeus and Maine is the
delay in reaching care. Although initially described in refer-
ence to geographic obstacles in a global context, this can also
be applied to our local labor and delivery units. The delay in
reaching care in our context is equivalent to the delay in the
patient receiving care while on the unit. The care is available and
at the hospital, but the patient experiences a delay in reaching
that care. Blood bank readiness, rapid access to medications and
equipment, and team response time are all key factors.
The Three Delays Model is a continuum, with the third delay
experienced by patients who have succeeded in avoiding or
overcoming the rst two delays. The delay in receiving quality
care is the most tragic and least acceptable in our high resource
settings. The response to a recognized PPH should be swift and
precise. Simulation drills, team training, the use of standardized
stage based checklists, and good communication within and
between teams/departments are key aspects of assuring an
adequate response and quality care to these patients.
A potential solution: Obstetric hemorrhage safety
bundles
Given the signicant contribution to severe maternal morbid-
ity and mortality, along with the often-preventable nature of
 SEM I N A R S I N P E R I N A T O L O G Y
severe postpartum hemorrhage, efforts focused on preven-
tion, early recognition, and optimal management are
sought.2427 Standardization of care, using bundles of evi-
dence based guidelines and processes, has been described as
a potential solution, which may aid in this important shared
goal.28,29 Obstetric hemorrhage bundles or safety programs
have been implemented successfully with improved out-
comes demonstrated.3033 This is promising and suggests
that development and state-wide implementation of a stand-
ardized bundle including resources for Obstetric Hemorrhage
has the potential to decrease preventable maternal morbidity
and mortality in New York state through the Safe Mother-
hood Initiative.27
re fe r en ces
1. Say L, Chou D, Gemmill A, et al. Global causes of maternal
death: a WHO systematic analysis. Lancet Glob Health. 2014;2
(6):e323e333.
2. Souza JP, Gulmezoglu AM, Vogel J. Moving beyond essential
interventions for reduction of maternal mortality (the WHO
Multicountry Survey on Maternal and Newborn Health): a
cross-sectional study. Lancet. 2013;381(9879):17471755.
3. Calvert C, Thomas SL, Ronsmans C, Wagner KS, Adler AJ,
Filippi V. Identifying regional variation in the prevalence of
postpartum haemorrhage: a systematic review and meta-
analysis. PLoS One. 2012;7(7):e41114.
4. Creanga AA, Berg CJ, Syverson C, et al. Pregnancy-related
mortality in the United States, 2006-2010. Obstet Gynecol.
2015;125(1):512.
5. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins
GD. Maternal death in the 21st century: causes, prevention,
and relationship to cesarean delivery. Am J Obstet Gynecol.
2008;199(1):36e136e9.
6. Kramer MS, Berg C, Abenhaim H, et al. Incidence, risk factors,
and temporal trends in severe postpartum hemorrhage. Am J
Obstet Gynecol. 2013;209(449):e1e7.
7. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum
hemorrhage in high resource countries: a review and recom-
mendations from the International Postpartum Hemorrhage
Collaborative Group. BMC Pregnancy Childbirth. 2009;9:55.
8. Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum
hemorrhage: United States, 19942006. Am J Obstet Gynecol.
2010;202(353):e1e6.
9. Ford JB, Roberts CL, Simpson JM, Vaughan J, Cameron CA.
Increased postpartum hemorrhage rates in Australia. Int J
Gynecol Obstet. 2007;98(3):237243.
10. Joseph KS, Rouleau J, Kramer MS, Young DC, Liston RM,
Baskett TF. Investigation of an increase in postpartum
haemorrhage in Canada. Br J Obstet Gynaecol. 2007;114(6):
751759.
11. Lutmoski JE, Byrne BM, Devane D, Greene RA. Increasing
trends in atonic postpartum haemorrhage in Ireland: an 11-
year population-based cohort study. Br J Obstet Gynaecol.
2012;119(9):306314.
12. American Congress of Obstetricians and Gynecologists and State of
New York Department of Health. Safe Motherhood Initiative;
20072009. Triennial Report. Unpublished data.
13. Pregnancy Associated Mortality, New York City; 20012005.
http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-repor
t-online.pdf.
14. Grobman WA, Bailit JL, Rice MM, et al. Frequency of and
factors associated with severe maternal morbidity. Obstet
Gynecol. 2014;123(4):804810.
] (2015) ]]]]]] 3
15. Callaghan WM, Creanga AA, Kuklina EV. Severe maternal
morbidity among delivery and postpartum hospitalizations in
the United States. Obstet Gynecol. 2012;120(5):10291036.
16. Thaddeus S, Maine D. Too far to walk: maternal mortality in
context. Soc Sci Med. 1994;38(8):10911110.
17. WHO. The prevention and management of postpartum haemor-
rhage. Report of a technical working group, Geneva 36 July
1989. World Health Organization/Maternal and Child Health
90.7.Geneva: WHO; 1990.
18. American College of Obstetricians and Gynecologists. ACOG
practise bulletin: clinical management guidelines for obste-
trician-gynecologists, No. 76, October 2006. Postpartum hem-
orrhage. Obstet Gynecol. 2006;108(4):10391047.
19. ACOG. reVITALize Obstetric Data Denitions. 2014. http://www.
acog.org/About-ACOG/ACOG-Departments/Patient-Safe
ty-and-Quality-Improvement/reVITALize-Obstetric-Data-De
nitions; Accessed 11.04.15.
20. Della Torre M, Kilpatrick SJ, Hibbard JU, et al. Assessing
preventability for obstetric hemorrhage. Am J Perinatol. 2011;28
(10):753760.
21. Patel A, Goudar SS, Geller SE, et al. Drape estimation vs. visual
assessment for estimating postpartum hemorrhage. Int J
Gynaecol Obstet. 2006;93(3):220224.
22. Stafford I, Dildy G, Clark S, Belfort M. Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J
Obstet Gynecol. 2008;199(519):e1e7.
23. Toledo P, Eosakul S, Goetz K, Wong C, Grobman W. Decay in
blood loss estimation skills after web-based didactic training.
Simul Healthc. 2012;7(1):1821.
24. Lyndon A, Lagrew D, Shields L, Main E, Cape V. Improving
Health Care Response to Obstetric Hemorrhage. (California Mater-
nal Quality Care Collaborative Toolkit to Transform Maternity
Care) Developed under contract 11-10006 with the California
Department of Public Health; Maternal, Child and Adolescent
Health Division; Published by the California Maternal Quality
Care Collaborative; 17.03.15.
25. National Partnership for Maternal Safety. Council for Patient Safety
in Womens Health Care. http://www.safehealthcareforevery
woman.org/maternal-safety.html.
26. The Joint Commission. Preventing Maternal Death. Sentinel Event
Alert, 44, 14. http://www.jointcommission.org/assets/1 /18/
SEA_44.PDF; 2010.
27. American College of Obstetricians and Gynecologists. Safe
motherhood initiative. http://www.acog.org/About-ACOG/
ACOG-Districts/District-II/SMI-Registration.
28. American College of Obstetricians and Gynecologists. Clinical
guidelines and standardization of practice to improve out-
comes. Committee opinion no. 629. Obstet Gynecol. 2015;125(4):
10271029.
29. Institute for Healthcare Improvement. What is a Bundle? http://
www.ihi.org/knowledge/Pages/ImprovementStories/WhatIsa
Bundle.aspx.
30. Einerson BD, Miller ES, Grobman WA. Does a postpartum
hemorrhage patient safety program result in sustained
changes in management and outcomes? Am J Obstet Gynecol.
2015;212(2): 140.e1144.e1.
31. Lappen JR, Seidman D, Burke C, Goetz K, Grobman WA.
Changes in care associated with the introduction of a post-
partum hemorrhage patient safety program. Am J Perinatol.
2013;30(10):833838.
32. Shields LE, Smalarz K, Refgee L, Mugg S, Burdumy TJ, Propst
M. Comprehensive maternal hemorrhage protocols improve
patient safety and reduce utilization of blood products. Am J
Obstet Gynecol. 2011;205(4):368.e1368.e8.
33. Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive
maternal hemorrhage protocols reduce the use of blood
products and improve patient safety. Am J Obstet Gynecol.
2015;212(3):272280.