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.
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 number of women transfused, and this has likely decreased because of prevailing conservative attitudes towards blood replacement. For example, in older studies, the incidence of postpartum hemorrhage was cited to be 3.9 percent in women delivered vaginally and 6 to 8 percent in those undergoing cesarean delivery (Combs and associates, 1991a, b; Naef and colleagues, 1994). In a recent 24-center investigation from Argentina and Uruguay, Sosa and colleagues (2009) used especially made plastic sheets to collect blood shed at delivery. They reported that 10.8 percent of women lost more than 500 mL, and 1.9 percent lost greater than 1000 mL. In another recent population-based study of more than 66,000 women delivered at Parkland Hospital from 2002 to 2006, Alexander and colleagues (2009) reported that 2.3 percent were given blood transfusions for hypovolemia. Half of these had undergone cesarean delivery, and this is related to the substantively increased maternal mortality and severe morbidity rate with cesarean compared with vaginal delivery (Alexander, 2009; Clark, 2008; Pallasmaa, 2008, and all their colleagues).
When these prospective audits are compared with evaluations using discharge statistics, it is apparent that hemorrhage is underreported. Recently, Berg and colleagues (2009) from the Centers for Disease Control and Prevention sampled nearly 185,000 hospitalizations for delivery in the National Hospital Discharge Summary database representing more than 40 million deliveries in the United States from 1993–1997 and 2001–2005. For these two epochs, the incidence of postpartum hemorrhage by ICD-9-CM codes was 2.0 and 2.6 percent, respectively. The rate for transfusions in these women between 1991 and 2003 increased from 3 per 1000 deliveries to 5 per 1000. These incidences are far below those reported in the studies above.
Table 35-1 lists the many clinical circumstances in which risk of hemorrhage is appreciably increased. It is apparent that serious hemorrhage may occur at any time throughout pregnancy and the puerperium. Although the timing of bleeding is widely used to classify obstetrical hemorrhage, the term third-trimester bleeding is imprecise, and its use is not recommended.
Table 35-1. Causes and Predisposing Factors of Obstetrical Hemorrhage
| Save Table
Table 35-1. Causes and Predisposing Factors of Obstetrical Hemorrhage
Distension with clots
Trauma During Labor and Delivery
Anesthesia or analgesia
Complicated vaginal delivery
Low- or midforceps delivery
Conduction analgesia with hypotension
Cesarean delivery or hysterectomy
Uterine rupture-risk increased by:
Previously scarred uterus
Oxytocin or prostaglandin stimulation
Previous uterine atony
Coagulation Defects—Intensify Other Causes
Small Maternal Blood Volume
Pregnancy hypervolemia not yet maximal
Severe preeclampsia and eclampsia
Pregnancy hypervolemia constricted
Amnionic fluid embolism
Log In to View More
If you don't have a subscription, please view our individual subscription options
below to find out how you can gain access to this content.
Want access to your institution's subscription?
Sign in to your MyAccess Account while you are actively authenticated on this website
via your institution (you will be able to tell by looking in the top right corner
of any page – if you see your institution’s name, you are authenticated). You will
then be able to access your institute’s content/subscription for 90 days from any
location, after which you must repeat this process for continued access.
If your institution subscribes to this resource, and you don't have a MyAccess account,
please contact your library's reference desk for information on how to gain access
to this resource from off-campus.
AccessMedicine Full Site: One-Year Subscription
Connect to the full suite of AccessMedicine content and resources including more than 250 examination and procedural videos, patient safety modules, an extensive drug database, Q&A, Case Files, and more.
Pay Per View: Timed Access to all of AccessMedicine
48 Hour Subscription
Pop-up div Successfully Displayed
This div only appears when the trigger link is hovered over.
Otherwise it is hidden from view.