| |

Received: 21 December 2020    Revised: 5 March 2021    Accepted: 9 March 2021

DOI: 10.1002/ijgo.13823

CLINICAL ARTICLE
Obstetrics

The golden hour for postpartum hemorrhage: Results from a

prospective cohort study

Rodolfo C. Pacagnella1 | Anderson Borovac-­Pinheiro1  | Carla Silveira1 |

Sirlei Siani Morais1 | Juliana Luz Passos Argenton2 | Joao Paulo Souza3 |
Andrew D. Weeks4 | José G. Cecatti1

1
Department of Obstetrics and
Gynecology, School of Medical Sciences, Abstract
University of Campinas, Campinas, Brazil
Objective: To evaluate the predictive capacity of vital signs for the diagnosis of post-
2
Statistics Unit, School of Medical
Sciences, University of Campinas,
partum hemorrhage (PPH).
Campinas, Brazil Methods: A prospective cohort study performed at the University of Campinas, Brazil,
3
Department of Social Medicine, Ribeirao between February 2015 and March 2016 with women who delivered vaginally. Vital
Preto Medical School, University of São
Paulo, Ribeirao Preto, Brazil signs and postpartum bleeding were collected over 24 h. Exploratory data analysis
4
Sanyu Research Unit, Department of was performed plus receiver operating characteristic curve analysis where the areas
Women's and Children's Health, University
under the curve was used to determine the best cutoff points for sensitivity, specific-
of Liverpool, Liverpool, UK
ity, likelihood ratio, and diagnostic odds ratio.
Correspondence
Results: For the 270 women recruited, mean blood loss after 120 min was
Anderson Borovac-­Pinheiro, Department
of Obstetrics and Gynecology, University 427.49 ± 335.57 ml, while 84 (31.1%) and 22 (8.1%) women had blood loss ≥500 and
of Campinas, Campinas, São Paulo, Brazil.
≥1000 ml, respectively. Heart rate cutoff point of 105 bpm measured between 21–­
Email: andersonpinheiro.unicamp@gmail.
com 40 min after birth identified blood loss ≥1000 ml with 90% specificity. A shock index
(SI) of 0.965 at 41–­60 min after birth identified blood loss ≥500 and ≥1000 ml within
Funding information
This research was funded by CEMICAMP 2 h with approximately 95% specificity.
and Faepex–­Unicamp (grant number
Conclusion: Shock index and heart rate measured after birth showed high specificity
PAPDIC/2714). The funders were not
involved in study design or interpretation with low sensitivity to identify PPH. In clinical practice, “The rule of 1s” should receive
of results nor in the decision to publish.
special attention: SI ≥1, or heart rate >100 bpm, or estimated blood loss ≥1 L.

KEYWORDS
blood loss, heart rate, postpartum hemorrhage, shock index, vital signs

1  |  I NTRO D U C TI O N condition.4–­6 PPH is also associated with maternal near-­miss cases,

Postpartum hemorrhage (PPH) has been a leading cause of global
maternal mortality over the last 25 years.1,2 It affects mainly young
women in low-­and middle-­
income countries and its impact on
maternal mortality has increased from 68% in 1990 to more than
80% in 2015.1–­3 PPH has also increased in high-­income countries
where there is a higher rate of medicalization contributing to the
Intensive care unit (ICU) admission, and massive blood transfusion.7,8
Given the low ability to predict PPH according to prelabor charac-
teristics, early recognition and treatment of PPH are essential.9,10 The
World Health Organization (WHO) defines PPH as blood loss >500 ml
within 24 h after childbirth and severe PPH as blood loss >1000 ml.11
Although these thresholds may not necessarily imply se-
vere maternal morbidity or serious hazard to women, they are

© 2021 International Federation of Gynecology and Obstetrics

Int J Gynecol Obstet. 2021;00:1–9.  |

wileyonlinelibrary.com/journal/ijgo     1
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2      PACAGNELLA et al.
commonly used to identify PPH. Thus, a new definition for PPH
has been suggested that includes vital signs, particularly shock
index (SI).12 In addition, assessment of blood loss visually in daily
practice has significant limitations, therefore other parameters
may be a useful alternative to identify PPH. This could improve
individualization and diagnostic ability as monitoring continues for
at least 24 h. Nevertheless, hemodynamic and other physiological
adaptations during pregnancy may compensate for blood loss, de-
laying identification of women at risk of severe outcomes. As such,
some women will tolerate blood loss of 500 ml or more and not
show an increased risk of mortality, whereas others may bleed less
and show an increased risk.
To date, no single parameter has been found to identify those
women at risk. Traditional vital signs and hemoglobin/hematocrit
13–­15
levels have not been found useful for this purpose. However,
SI—­the ratio of heart rate to systolic blood pressure—­has been iden-
tified as a promising predictor of blood loss during pregnancy and
16
childbirth. Blood loss tends to increase heart rate and reduce sys-
tolic blood pressure and any change in these parameters is maxi-
mized by a ratio between them with increased sensitivity of the
indicator.16,17
In early pregnancy, a relationship has been identified between
increased SI values and ruptured ectopic pregnancy with hemoperi-
toneum.18–­21 Other retrospective studies found a strong relation-
ship between higher SI values and severe maternal outcomes. 22–­26
SI is a strong predictor of maternal death, organ dysfunction, and
emergency hysterectomy.17 However, the role of the SI is not yet
well established for the diagnosis of PPH. Therefore, we designed
a prospective study to systematically collect data using carefully
measured blood loss volumes and automated vital sign assessments.
The aim of the present study was to systematically evaluate
postpartum bleeding and vital signs parameters during vaginal de-
livery and to assess the relationship between traditional vital signs,
SI, and volume of blood loss measured prospectively during 24 h fol-
lowing vaginal birth. We hypothesized that the SI would have a good
correlation with the amount of blood loss and could be used as a
trigger for the treatment of PPH.
2  |  M ATE R I A L S A N D M E TH O DS
A prospective cohort study was conducted at the University of
Campinas Women's Hospital, Brazil, between February 1, 2015 and
March 31, 2016. All women giving birth vaginally were eligible to
participate. Women were ineligible if they underwent cesarean de-
livery, were below 34 weeks of gestational age, had hypertension,
hyper-­or hypothyroidism without treatment, any cardiac disease,
infections with fever or sepsis, a history of coagulopathy, or if child-
birth occurred after 7 pm.
Two trained research assistants were at the labor ward to collect
data during workdays from 9 am to 9 pm (the limited work time was
due to budget constraints). Women in labor were invited to partici-
pate in the study during admission to hospital. They were provided
with full information about the study and, if they accepted, signed
an informed consent form; if the participant was an adolescent, a
guardian also signed the consent form. Women were included only
if they had a vaginal birth once data collection had started and if
the birth occurred prior to 7 pm to ensure that measurement of
vital signs occurred within 2 h after birth, as determined by the re-
search protocol. Women were excluded if the birth occurred after
7 pm or before 9 am. The Institutional Review Board of University of
Campinas, Brazil approved the study (26787114.3.0000.5404).
Sample size was estimated based on the need for 28 women with
blood loss over 1000 ml to demonstrate the performance of the SI
by the area under the receiver operating characteristic (ROC) curve
of 0.800 with a 95% confidence interval of 0.700–­0.925 according
to the calculations of previous studies. 27
Immediately after the birth and flow of all amniotic fluid and
urine, a calibrated drape (Maternova, Providence, RI, USA) was
placed under each woman's buttocks to measure blood loss. At the
same time, all compresses and gauzes used during the birth OK were
collected and weighed. The dry weight of the compresses was sub-
tracted from the wet weight to calculate blood volume. For estima-
tion of volume, we considered the density of blood as 1 g/ml. 28 All
women received prophylactic 10 IU oxytocin intravenously or intra-
muscularly after birth as per institutional protocol.
Immediately after birth with participants in the recumbent po-
sition and the drape in place, we commenced systematic collec-
tion of data on heart rate, systolic and diastolic blood pressure,
respiratory rate, and oxygen saturation, along with total blood
loss (drape plus weight of compresses). After the first 2 h, blood
loss was collected on sanitary pads that were stored in an airtight
sealed plastic bag for weighing after each change. Vital signs were
obtained using an automatic multiparameter monitor (DX 2020;
Dixtal, Wallingford, CT, USA) during the first 2 h and manually
after that until 24 h.
Data were collected every 5 min up to 30 min after birth, then
every 15 min up to 2 h after birth, and routinely up to 24 h after
birth. In addition, information was collected on any infusions admin-
istered within the first 2 h. Interventions for PPH treatment were
guided by institutional protocols, according to diagnosis by the ob-
stetrician in charge and not by the research assistant; the volume of
blood loss and vital signs were communicated to the clinician by the
research assistant only if they were asked to provide them.
Exploratory data analysis was performed to assess mean, stan-
dard deviation, minimum, median, maximum, frequency, percentage,
and percentiles. Mean values of vital signs were observed over the
following intervals: 0–­20 min, 21–­4 0 min, 41–­60 min, 61–­90 min, and
91–­120 min. The Spearman rank correlation coefficient was used to
assess the correlation between variables and blood loss. Missing
data were not considered in the analysis. A generalized estimating
equation model was used to evaluate the relationship between vital
signs and blood loss over time. At each interval we assessed blood
loss and used ROC analysis to determine the best cutoff point for
vital signs to assess blood loss ≥500 and ≥1000 ml within two and
24 h after birth. The areas under the curve (AUC) used the threshold
PACAGNELLA et al. |
      3

TA B L E 1  Sociodemographic, birth, and outcome data of the 270

points of vital signs, sensitivity, specificity, likelihood ratios, and di-
participants
agnostic odds ratio. We defined a significance level of 5% and SAS
version 9.4 (SAS Institute, Cary, NC, USA) was used for analyses. No. (%)
Characteristics (n = 270) Mean ± SD

Sociodemographic

3  |   R E S U LT S Age, year 24.67 ± 6.19

Body mass index (antepartum) 28.85 ± 4.61a 
There were 3238 births in our hospital over the study period, com- Gestational age, week 38.93 ± 1.47
prising 1692 vaginal births. Taking account of the limited time period Education, year 9.91 ± 2.46b 
for data collection and the eligibility criteria, a total of 319 women Ethnicity  c

were eligible and gave informed consent to participate. Of these, 8

White 178 (67.7)
(2.5%) women later withdrew and 41 (12.9%) had a cesarean sec-
Nonwhite 85 (32.3)
tion after the onset of labor, leaving 270 (84.6%) participants. All
Parity
included women completed the study. Sociodemographic, birth,
Primiparous 124 (45.9)
and summary outcome data are shown in Table 1. Mean blood loss
Multiparous 146 (54.1)
at 120 min was 427.49 ml ± 335.57. A total of 168 (62.2%) women
Birth data
received an epidural, spinal anesthesia, or a combination of both,
while 100 (37.8%) women received no analgesia. There were 189 Onset of labor

(70.0%) women who received antepartum oxytocin. In the first 2 h Spontaneous 203 (75.2)
after childbirth, 84 (31.1%) and 22 (8.1%) women had blood loss of Induced 67 (24.8)
>500 and 1000 ml, respectively. By 24 h, 120 (44.4%) and 34 (12.6%) Regional anesthesia
women had blood loss >500 and 1000 ml, respectively. Additional None 100 (37.0)
treatment doses of oxytocin and ergometrine were administered to Spinal anesthesia 13 (4.8)
19 (7.0%) and 2 (0.7%) women, respectively. Among women with Epidural 22 (8.1)
blood loss of <500 ml, 67 (24.8%) lost ≤300 ml, whereas 107 (39.6%)
Spinal and epidural 135 (50.0)
lost ≤400 ml in 24 h.
Mode of delivery
Figure 1 shows the distribution of blood loss over time follow-
Vaginal spontaneous 247 (91.5)
ing birth. Overall, nearly three quarters (73%) of blood loss occurred
Forceps 23 (8.5)
within 40 min of birth and significantly reduced after that. There was
Oxytocin infusion 189 (70.0)
little additional blood loss between 40 min and 24 h, even for those
with higher total blood loss volumes. Episiotomy 96 (35.6)

Of the traditional vital signs, systolic blood pressure, diastolic Mean initial hemoglobin level, 11.45 ± 1.11
g/Ld 
blood pressure, and respiratory rate showed no significant correla-
tion with blood loss at any time over the first 24 h. Heart rate was Outcome data

positively correlated with blood loss (P  < 0.001), with a Spearman Oxytocin for PPH treatment 19 (7.0)

rank correlation coefficient of 0.31 at 21–­4 0 min and 0.44 after Ergometrine for PPH treatment 2 (0.7)
90 min. Oxygen saturation had a weak correlation with blood loss at Blood loss in the first 120 min, 427.49 ± 335.57
41–­60 min only (P < 0.001; r = 0.147). ml

Shock index was also correlated with blood loss. Figure 2 shows ≥500 84 (31.1)

the distribution of mean SI values during all periods by the amount ≥750 41 (15.2)
of blood loss in the first 24 h. Women who had blood loss ≤500 ml in ≥1000 22 (8.1)
24 h had mean SI values <0.8 in the same period. In contrast, most Total blood loss in the first 24 h, ml
women who had blood loss ≥600 ml had mean SI values >1.0. ≥500 120 (44.4)
Mean SI at all time intervals was positively correlated with the ≥750 68 (25.2)
volume of blood loss at the respective intervals. In the same way,
≥1000 34 (12.6)
mean SI was positively correlated with the total volume of blood loss c
Mean final hemoglobin level, g/L   10.6 ± 1.58
at two and 24 h (Figure 3). Nevertheless, the generalized estimating
Abbreviation: PPH, postpartum hemorrhage.
equation model performed to evaluate the relationship between SI
a
Missing data: n = 26.
and blood loss over time showed no significance (P = 0.3835). b
Missing data: n = 39.
Since the majority of blood loss occurred within the first hour c
Missing data: n = 7.
after delivery, we evaluated vital signs as an adjuvant tool to identify d
Missing data: n = 10.
PPH in this time period. Table 2 shows the ability of heart rate and SI
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4      PACAGNELLA et al.

F I G U R E 1  Cumulative blood loss curves in the first 2 h after vaginal birth according to blood loss percentiles (P) 24 h after delivery

F I G U R E 2  Distribution of shock index values by the amount of blood loss. Each data point is classified according to its blood loss
percentile (P) 24 h after delivery

to identify blood loss in the first hour after birth. The cutoff points
for heart rate ranged from 87 to 91 bpm for blood loss ≥500 ml and
from 93 to 105  bpm for blood loss ≥1000  ml. At 21–­4 0  min, the
cutoff point for heart rate was 91 bpm for blood loss >500 ml within
2 h, and it was 105 bpm for blood loss >1000 ml in 2 h. SI cutoff
points ranged from 0.785 to 0.965 for blood loss ≥500 ml and from
0.785 to 0.965 for blood loss ≥1000  ml. At 21–­4 0  min, the cutoff
point for SI was 0.805 for loss >500 ml in 2 h and 0.785 for blood
loss >1000 ml both in two and 24 h.
A sensitivity of over 70% was found for SI measured more
than 60 min after birth. Specificity was higher at 41–­6 0 min (over
93.6%) for all outcomes. The positive likelihood ratios were higher
at 41–­6 0 min. Table 3 shows the sensitivity, specificity, positive
and negative predictive values, and likelihood ratio for SI above
0.8, 0.9, and 1.0 to identify postpartum blood loss >1000 ml in 2 h.
Figure 4 shows the comparison of mean SI values and standard
deviation among women who experienced PPH and those that did
not.
Use of fluid infusion, anesthesia, and body mass index did not
affect SI values (P = 0.31, 0.08, and 0.16, respectively).
Four women received blood transfusions, with blood loss of 747,
1296, 1601, and 1879 ml within 24 h after birth. The SI values for
these four women were higher compared with women who did not
have a transfusion. Mean SI ranged from 0.86 to 0.92 in those re-
ceiving red cell transfusion and from 0.71 to 0.75 among those who
did not receive a blood transfusion (Mann–­Whitney, P  = 0.024 at
21–­4 0 min and 0.048 at 41–­60 min). No women in the study were
admitted to the ICU or had additional surgical procedures.
4  |  D I S C U S S I O N
The present study found that SI and heart rate were positively cor-
related with blood loss; however, they showed poor diagnostic ac-
curacy for the identification of women with blood loss of 500 ml
or more after birth. Other vital signs showed no clinically relevant
PACAGNELLA et al.
F I G U R E 3  Scatter plot graph for mean shock index (SI) at selected periods and total blood loss (BL) in 2 and 24 h after delivery
correlation with blood loss. Furthermore, most blood loss after birth
was found to occur within 40 min after birth.
Mean blood loss after 120  min was 427.49  ml in the present
study. This is in line with other studies, although there was wide vari-
ation between studies in the volume of blood measured. 29,30 Other
studies that used drapes to estimate blood loss reported lower val-
ues for mean blood loss, ranging from 233 to 302 ml.31–­33
Differences were also found in the incidence of PPH. In our
study, 31.1% had criteria for a PPH diagnosis according to the cur-
rent WHO definition (≥ 500 ml), and 8.1% had severe PPH, whereas
other studies reported the incidence of PPH as 9.0% and 14.9%31,32
31
with a very low incidence of severe PPH (1.2%). This high fre-
quency of women with PPH in the present study may, in part, be a
consequence of the augmentation of labor, (e.g. the oxytocin use,
artificial rupture of membranes, etc) that have made labor and deliv-
ery not completely natural.
The higher prevalence of PPH may also be a consequence of the
rigorous methods used to measure blood loss in the present study.
OK Among the methods used to evaluate blood loss after birth, use
of the drape combined with the weight of pads and compresses is
a more effective method of identifying accurate volume of blood
loss.34
The present study evaluated vital signs and bleeding prospec-
tively after birth, using a rigorous method for measurement of blood
loss in a healthy pregnant population. It found that most postpartum
bleeding occurred within 40 min after delivery. This highlights the
importance of postpartum monitoring that should be performed by
the birth attendant primarily during the first hour after delivery. The
present study found that SI and heart rate values directly correlate
with blood loss. Heart rate and SI may reflect cardiovascular changes
due to postpartum blood loss, and both showed better specific-
ity than sensitivity to identify women at risk of severe bleeding.
|
      5
Therefore, SI and HR can be used as an adjuvant tool (not alone) to
identify women at risk of severe maternal outcomes due to PPH.
Retrospective studies have shown that SI was related to massive
PPH and severe maternal outcomes.17,23,24,35 Compared with other
vital signs, SI is better at predicting adverse outcomes in women
with blood loss >1500  ml; a cutoff point of ≥0.9 indicates referral
to a higher-­level facility.35 This cutoff of 0.9 at 30 min after birth
was recommended in another retrospective study to help identify
women with massive PPH. 23 SI values ≥0.9 are considered a good
predictor of maternal death, with 100% sensitivity but low specific-
ity (5.3%).17
However, even for blood loss >1000 ml, this threshold does not
necessarily mean a clinically relevant hazard, and may not represent
a real risk of maternal death due to PPH. However, the cutoff points
for heart rate and SI can be used as an alert to identify those at
risk of a severe maternal outcome and may influence the initiation of
strict monitoring and/or to start treatment for PPH.36 Therefore, di-
agnosis of PPH should be performed in two steps using postpartum
bleeding and vital signs, particularly SI, for the early identification
of PPH.
Although almost 50% of our sample would be classified as hav-
ing PPH based on the WHO definition,11 a minority of these women
were clinically diagnosed with PPH and received an additional dose
of oxytocin or ergometrine, and none required ICU admission or ad-
ditional surgical procedures. This suggests that the definition of PPH
based on volume of blood loss should be reconsidered and highlights
the need for a clinical parameter to trigger intervention in women
who are at risk of cardiovascular decompensation due to PPH.12,37
Considering that most blood loss took place within 40 min
after birth, any clinical sign to trigger treatment for PPH must
be measured within this period or soon after, when the cardio-
vascular system may show collapse. A heart rate cutoff point of
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6      PACAGNELLA et al.

TA B L E 2  Performance of heart rate and shock index within the first hour to identify blood loss of at least 500 and 1000 ml within 2 and
24 h after birth

Time period, Cutoff Sensitivity (95% Specificity (95% Likelihood

Blood loss mins AUC (95% CI) point CI) CI) ratioa  DOR

Heart rate
≥500 ml in 2 h 21–­4 0 0.68 (0.602–­0.748) 91.2 59.0 (53.1–­6 4.9) 73.0 (67.7–­78.3) +2.19; 3.89
–­0.56
41–­60 0.69 (0.617–­0.754) 87.5 63.1 (55.9–­67.7) 66.5 (65.1–­76.1) +2.10; 3.39
–­0.54
≥500 ml in 24 h 21–­4 0 0.64 (0.572–­0.707) 90.8 50.4 (44.3–­56.5) 74.1 (68.8–­79.4) +1.95; 2.91
–­0.67
41–­60 0.66 (0.591–­0.722) 87.6 57.5 (51.5–­63.5) 70.6 (65.1–­76.1) ±1.96; –­0.6 3.25
≥1000 ml in 2 h 21–­4 0 0.71 (0.558–­0.864) 105.2 54.5 (48.5–­60.5) 90.2 (86.6–­93.8) +5.56; 11.02
–­0.50
41–­60 0.72 (0.591–­0.853) 97.5 59.1 (53.2–­65.0) 81.4 (76.8–­86.0) +3.18; 6.32
–­0.50
≥1000 ml in 24 h 21–­4 0 0.66 (0.546–­0.776) 93.1 61.8 (55.9–­67.7) 70.6 (65.1–­76.1) +2.10; 3.88
–­0.54
41–­60 0.67 (0.566–­0.776) 99.2 44.1 (38.1–­50.1) 86.0 (81.8–­90.2) +3.15, 4.85
–­0.65
Shock index
≥500 ml in 2 h 21–­4 0 0.64 (0.565–­0.708) 0.805 42.6 (36.7–­48.5) 76.3 (71.2–­81.4) +1.80; 2.39
–­0.75
41–­60 0.64 (0.567–­0.707) 0.965 24.6 (19.5–­29.7) 95.5 (93.0–­98.0) +5.47; 6.92
–­0.79
≥500 ml in 24 h 21–­4 0 0.65 (0.579–­0.713) 0.785 52.9 (46.8–­59.0) 73.3 (67.9–­78.7) +1.98; 3.08
–­0.64
41–­60 0.64 (0.572–­0.705) 0.965 31.4 (25.8–­37.0) 93.6 (90.6–­96.6) +4.91; 6.69
–­0.73
≥1000 ml in 2 h 21–­4 0 0.67 (0.523–­0.819) 0.785 56.1 (50.1–­62.1) 74. 7 (69.5–­79.9) +2.22; 3.77
–­0.59
41–­60 0.67 (0.541–­0.801) 0.965 36.6 (30.8–­42.4) 95.2 (92.6–­97.8) + 7.63; 11.45
–­0.67
≥1000 ml in 24 h 21–­4 0 0.65 (0.539–­0.759) 0.785 44.8 (38.8–­50.8) 75.6 (70.4–­8 0.8) + 1.84; 2.51
–­0.73
41–­60 0.64 (0.534–­0.749) 0.965 25.0 (19.8–­3 0.2) 95.9 (93.5–­98.3) + 6.10; 7.80
–­0.78

Abbreviations: AUC, area under the curve; DOR, diagnostic odds ratio; PPH, postpartum hemorrhage.
a
Likelihood ratio (LR): Positive = sensitivity/(1–­specificity); LR 5–­10: moderate effect on increasing the probability of PPH; LR <5: Small effect on
increasing the probability of PPH; negative = (1–­sensitivity)/specificity; LR <0.1: large effect on decreasing the probability of PPH; LR 0.5–­0.1:
moderate effect on decreasing the probability of PPH.

TA B L E 3  Performance of shock index between 21 and 60 min after delivery to identify blood loss >1000 ml within 2 h after birth

Sensitivity Specificity PPV NPV Accuracy PLR NLR

Vital signs within 21 and 40 min after delivery

≥0.8 63.6 74.2 18.2 95.8 73.3 2.5 0.5
≥0.9 40.9 88.9 25.0 94.4 85.0 3.7 0.7
≥1.0 31.8 96.7 46.7 94.0 91.4 9.7 0.7
Vital signs within 41 and 60 min after delivery
≥0.8 50.0 73.7 14.5 94.3 71.8 1.9 0.7
≥0.9 36.4 85.8 18.6 93.8 81.8 2.6 0.7
≥1.0 27.3 94.7 31.6 93.6 89.2 5.2 0.8

Abbreviations: NLR, negative likelihood ratio; NPV, negative predictive value; PLR, positive likelihood ratio; PPV, positive predictive value.
PACAGNELLA et al.
F I G U R E 4  Comparison of mean shock index values and standard deviation among women who experienced postpartum hemorrhage
(PPH) and those who did not
105  bpm at 21–­4 0  min identified a final blood loss of ≥1000  ml
with 90% specificity. An SI of 0.965 at 41–­6 0 min identified blood
loss of ≥500 and 1000  ml, with approximately 95% specificity.
Since the sensitivity and specificity of vital signs are higher 40 min
after birth, we can deduce that postpartum bleeding occurs within
40 min and the clinical repercussions follow after that. Therefore,
SI is not a good tool to predict PPH; however, it can be useful for
early identification of PPH, and can be used to identify who will
have clinical repercussions due to postpartum bleeding. These val-
ues reflect hypovolemia and the attempt to compensate blood loss
with an increase in heart rate.
In addition, for women where early diagnosis was not made
within 40 min after birth, SI presented higher diagnostic odds ratios
after this period, showing that this vital sign could be used to formu-
late late diagnosis of PPH and help subsequent decisions on what
and when treatment for PPH should be initiated.
At this point, treatment implementation is necessary. In simple
terms, in every context where clinical signs can be gathered at
any moment after birth when heart rate is over 100 bpm and/or
approaches the value of systolic blood pressure, the woman is at
risk. 23
Nevertheless, considering that many women may bleed more
than 500 ml and will not be in a life-­threatening condition, it may
be better to identify those who will probably need intervention to
prevent a severe outcome.38 In the present study, lower SI values
indicate that the women did not have severe PPH. In daily practice
this means that if a woman has an SI ≥0.78 within 40 min of birth, the
probability of severe PPH is reduced by almost half.
|
      7
This information may lead us to consider further research of a dif-
ferent multilevel protocol for diagnosing and treating PPH. Some stud-
ies have discussed the use of misoprostol for secondary prevention
of PPH instead of universal prophylaxis. Secondary prevention using
800 µg of misoprostol may be as effective as 600 µg for primary pre-
vention of PPH and may have the advantages of fewer women being
treated, fewer adverse effects, and lower costs.38 Using this approach,
in conjunction with volume of blood loss, heart rate and SI may be use-
ful to identify those who will need treatment for PPH: an SI of 0.78
could be used to trigger secondary prevention, and heart rate over
105 bpm or SI of 0.95 could be used for PPH treatment.
Our study has several limitations. The small study population of
only 270 women meant that we had a low number of women with
severe maternal outcomes, ICU admission, hysterectomy, blood
transfusion, or maternal death. Furthermore, we did not analyze the
performance of vital signs to predict PPH in a second population
with different characteristics.
Given the potential harm caused by PPH, treatment should begin
as soon as necessary. However, due to cardiovascular changes in
pregnancy, shock diagnosis can be delayed, and hypotension may be
a late parameter to trigger intervention. Therefore, in clinical prac-
tice, it is important to identify situations that may lead to a critical
condition. The information from the present study could be used to
identify that critical situation and can be translated into “The rule
of 1s”: heart rate >100 bpm, or SI ≥1, or estimated blood loss ≥1 L.
In this situation, a woman should receive special attention, whether
intensive surveillance, or clinical or surgical treatment because of
the potential to evolve into a severe condition.
 |
8      PACAGNELLA et al.
11. Tunçalp O, Souza JP, Gülmezoglu M. New WHO recommendations
In conclusion, heart rate and SI measured after birth can be used
as an alert to identify women who have PPH and need close surveil-
lance and possible additional treatment. At this point, close surveil-
lance and intervention should be considered.
AC K N OW L E D G M E N T S
We thank all women who participated in this study and the medical
and nursing staff from CAISM who cared for participants and helped
collect the data. We are also grateful to the WHO for its support in
the design and implementation of this proposal.
C O N FL I C T S O F I N T E R E S T
The authors have no conflicts of interest.
AU T H O R C O N T R I B U T I O N S
RCP formulated the idea and RCP, JPS, and JGC conceived the
study. AB-­P, CS, and RCP collected the data. RCP, AB-­P, JLPA, and
SSM analyzed the data. AB-­P and RCP wrote the first version of the
manuscript. All authors contributed with amendments and sugges-
tions. AB-­P, ADW, and RCP wrote the final version and all authors
approved the final version.
ORCID
Anderson Borovac-­Pinheiro  https://orcid.org/0000-0002-2659-6012
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