Chapter 35

Obstetrics is “bloody business.” Although medical advances have dramatically reduced the dangers of childbirth, death from hemorrhage still remains a leading cause of maternal mortality. Hemorrhage was a direct cause of more than 17 percent of 4200 pregnancy-related maternal deaths in the United States as ascertained from the Pregnancy Mortality Surveillance System of the Centers for Disease Control and Prevention (Gerberding, 2003). Hemorrhage was the major factor for maternal deaths in the United Kingdom reported in the Confidential Enquiry into Maternal and Child Health (2008). In a private-sector report from the Hospital Corporation of America, Clark and co-workers (2008) reported that 12 percent of maternal deaths were caused by obstetrical hemorrhage. Finally, in many developed countries, hemorrhage is a leading reason for admission of pregnant women to intensive care units (Gilbert, 2003; Hazelgrove, 2001; Zeeman, 2003; Zwart, 2008, and all their associates).

In countries with fewer resources, the contribution of hemorrhage to maternal mortality rates is even more striking (Jegasothy, 2002; Rahman and co-workers, 2002). Indeed, hemorrhage is the single most important cause of maternal death worldwide. Obstetrical hemorrhage accounts for almost half of all postpartum deaths in developing countries (Lalonde and colleagues, 2006; McCormick and associates, 2002).

A number of reports exemplify the great improvement in mortality rates from hemorrhage with modernization of American obstetrics. Maternal deaths from hemorrhage in Massachusetts declined tenfold from the mid-1950s to the mid-1980s (Sachs and co-workers, 1987). Similarly, at Grady Memorial Hospital in Atlanta, maternal mortality rates from hemorrhage decreased from 13 percent between 1949 and 1971 to 6 percent between 1972 and 2000 (Ho and associates, 2002).

Some causes of severe obstetrical hemorrhage and their contribution to maternal mortality are shown in Figure 35-1. Fatal hemorrhage is most likely in circumstances in which blood or components are not available immediately. Moreover, Singla and associates (2001) reported that women who are Jehovah's Witnesses have a 44-fold increased risk of maternal death because of hemorrhage. Establishment and maintenance of facilities that allow prompt administration of blood are absolute requirements for acceptable obstetrical care.

###### Figure 35-1

Incidences of some causes of obstetrical hemorrhage and their contribution to maternal death from hemorrhage. Percentages are approximations because of different classification schemata used. (Data from Al-Zirqi, 2008a; Chichakli, 1999c; Zwart, 2008b, and all their colleagues.)

Generally speaking, obstetrical hemorrhage may be antepartum—such as with placenta previa or placental abruption, or more commonly it is postpartum—from uterine atony or genital tract lacerations.

### Incidence and Predisposing Conditions

The exact incidence of obstetrical hemorrhage is not known because of its imprecise definition as well as difficulty in its recognition and thus its diagnosis. One indicator is the ...

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