Postpartum haemorrhage: Aetiology and intervention
Postpartum haemorrhage is a leading cause of maternal morbidity and mortality worldwide. A common aetiology is uterine atony, which can often be related to the intrapartum management of labour; but an increasingly common cause is abnormally adherent placentation, which is occurring more often due to rising caesarean rates. While intervention can increase the risk of postpartum haemorrhage, it also has its place in its prevention. Hopefully, a balance can be found to improve outcomes both in the short- and long-term.
Postpartum haemorrhage is a major cause of maternal morbidity and mortality worldwide (Knight and Paterson-Brown, 2017). It accounts for one-quarter of all maternal deaths and 100 000 deaths every year, with one woman dying every 4 minutes as a result of postpartum haemorrhage alone (Sentilhes et al, 2015a; Sebghati and Chandraharan, 2017; Shakur et al, 2017). The picture is particularly bleak in low-resource regions such as sub-Saharan Africa, where the absence of skilled birth attendants at births, under-use or lack of uterotonics, and delayed access to emergency obstetric provision makes postpartum haemorrhage a major problem (Mpemba et al, 2014; Sheldon et al, 2014). The mortality rate due to postpartum haemorrhage has dramatically fallen in the UK, such that it is now relatively rare, with a mortality rate of 0.4 per 100 000 maternities, but in sub-Saharan Africa the rate is closer to 150 per 100 000 maternities (Weeks, 2014). As well as the extremely worrying maternal death rate, postpartum haemorrhage can result in severe maternal morbidity, including anaemia, the need for multiple blood transfusions, organ failure, and hysterectomy (Sheldon et al, 2014; Sebghati and Chandraharan, 2017); and the incidence of postpartum haemorrhage is increasing worldwide (Weeks, 2014; Nyfløt et al, 2017), despite the established use of preventative interventions such as active management of the third stage of labour (Say et al, 2014). In fact, this increase may be due, in part at least, to the increasing use of intervention during labour and birth (Weeks, 2014).
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