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Concerns over death rates from postpartum bleeding

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Concerns have been raised that not enough is being done to reduce death rates from excessive bleeding after childbirth, as revised guidelines are published to help healthcare professionals prevent and treat the condition.

A recent report on maternal deaths showed that while the number of mortalities relating to obstetric haemorrhage was still low, there has been no significant reduction since 2009.

The 2012-2014 Confidential Enquiries into Maternal Deaths and Morbidity report, published last week, identified 13 deaths from haemorrhage during that period, making it the third leading cause of direct maternal death in the UK.

”The fact that there has been no real reduction in death rates due to postpartum haemorrhage is a concern”

Louise Silverton

The importance of staff receiving updated training in this area was also stressed by the Royal College of Midwives after new research published today suggested a link between fertility treatments and an increased risk of severe postpartum haemorrhage.

Refreshed guidance has been published today by the Royal College of Obstetricians and Gynaecologists about how to prevent and treat postpartum haemorrhage (PPH), defined as losing 500ml of blood within 24 hours of childbirth.

It highlights that although in most cases there are no identifiable risk factors for PPH, these can include pre-existing blood disorders, multiple pregnancies, previous bleeding following childbirth, pre-eclampsia, a large baby and general anaesthetic.

Other risks factors are problems associated with the placenta, anaemia, prolonged labour, vaginal tears and episiotomy. The most common cause of PPH is when the uterus fails to contract, it says.

A combination of pharmacological, mechanical and surgical methods may need to be used to treat PPH and in severe cases, a hysterectomy may be required, states the guideline.

”PPH often occurs unexpectedly and can be very stressful for the woman and her partner or birth attendants. It is crucial that…they are kept informed”

RCOG guidelines on postpartum haemorrhage

Communication with the woman is key and those at risk of PPH should be advised to give birth in a hospital with a blood bank on site, it says.

“PPH often occurs unexpectedly and can be very stressful for the woman and her partner or birth attendants. It is crucial that, where feasible, they are kept informed and reassured, if appropriate, of the clinical development and proposed management,” says the guidance.

The guideline also emphasises the need for every maternity unit in the UK to have a protocol in place to treat a woman with the condition, and for training for all maternity staff to be provided, including rehearsals.

Dr Andrew Thomson, consultant obstetrician and co-chair of the RCOG guidelines committee, said: “PPH is an obstetric emergency therefore all staff involved in maternity care should have appropriate training in treating women who bleed excessively after childbirth.

“Although relatively rare in the UK, there has been no significant reduction in the number of women dying from obstetric haemorrhage since 2009.”

”PPH is an obstetric emergency therefore all staff involved in maternity care should have appropriate training”

Andrew Thomson

“These guidelines, which should be adopted by all obstetric-led units in the country, provide clinicians with best-practice advice and guidance on preventing and treating the condition,” he added.

Meanwhile, new research in the BJOG International Journal of Obstetrics and Gynaecology suggests that assisted reproductive technology (ART) could be associated with an increased risk of severe PPH, in particular amongst multiple pregnancies.

The study, which took place in Norway, found that among the 1064 cases of severe PPH – defined as blood loss of more than 1500ml or need for a blood transfusion – 10.8 % of the pregnancies were conceived by ART, in comparison to 4.0 % in the control group of a random sample of deliveries without severe PPH.

The study, called Assisted reproductive technology and severe postpartum haemorrhage: a case–control study, also found that the link was stronger in multiple pregnancies. Women with the combination of an ART pregnancy and multiples were considerably higher among the cases of severe PPH (4.5 %) than among the women in the control group (0.3 %).

The researchers recommended the use of single embryo transfer to reduce the multiple birth rate and emphasised the importance of explaining to couples about the possible risks of PPH from fertility treatments.

Royal College of Midwives

Quarter of stillbirth investigations ‘not good enough’

Louise Silverton

Commenting on the research, Louise Silverton, director for midwifery at the RCM, said: “This research highlights why it is so important that midwives and other maternity staff receive the appropriate training to recognise and treat post-partum haemorrhage, and that this training is refreshed regularly.”

“While the numbers of women dying from this are small in the UK, the fact that there has been no real reduction in death rates due to postpartum haemorrhage is a concern.”

She stressed the importance of ensuring greater continuity of care so that women are seen by the same group of midwives, who are then more able to spot developing problems.

In addition, midwives needed time to advise women about normal blood loss after birth as well which was currently a challenge due to the demands of the job, she said.

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