Postpartum hemorrhage: new

insights for definition and diagnosis

A. Borovac-Pinheiro, PhD; R. C. Pacagnella, PhD; J. G. Cecatti, PhD; S. Miller, PhD; A. M. El Ayadi, ScD, MPH;
J. P. Souza, PhD; J. Durocher, MA; P. D. Blumenthal, MD, MPH; B. Winikoff, MD, MPH

The current definition of is inadequate for early recognition of this important cause of maternal death that is responsible for >80,000 deaths worldwide
in 2015. A stronger definition of postpartum hemorrhage should include both blood loss and clinical signs of cardiovascular changes after delivery,
which would help providers to identify postpartum hemorrhage more promptly and accurately. Along with the amount of blood loss, clinical signs, and
specifically the shock index (heart rate divided by systolic blood pressure) appear to aid in more accurate diagnosis of postpartum hemorrhage.

Key words: postpartum hemorrhage, definition, clinical sign, shock index

In 2015 there were >80,000 maternal deaths caused by obstetric hemorrhage worldwide.1 Although there has
been a reduction in the absolute number of maternal deaths caused by hemorrhage over the last 25 years, it remains
the leading direct obstetric cause of maternal death. 1,2 Recent estimates suggest that 29.3% of maternal deaths
and 26.7% of severe adverse maternal outcomes globally are due to hemorrhage.1-3 Great variation exists regionally;
hemorrhage accounts for 9.3% of deaths in countries with a high socio-demographic index and 45.7% in countries
with a low sociodemographic index.1,2 Most deaths caused by hemorrhage occur in the postpartum period in both
high income countries (49.1%) and low-middle-income countries (73%).2 Among women with post-partum
hemorrhage (PPH), 17% will have either a maternal near miss or death; however, geographic disparities in the
incidence of severe maternal out-comes after PPH suggest the need to improve quality of care. 4
Prevalence estimates for PPH vary in the literature from 1e10% of all deliveries. Risk factors for PPH include
a variety of maternal factors (ie, advanced maternal age, nulliparity, anemia, previ-ous cesarean delivery, fibroid
tumors), pregnancy complications (ie, placenta previa or abruption, multiple gestation, polyhydramnios, amnionitis,
hypertensive disorders of pregnancy), and delivery characteristics (ie, episiotomy, retained placenta, laceration,
uterine rupture, high neonatal weight).5,6 However, the ability to predict PPH from antepartum and intrapartum risk
factors is very low.7 Therefore, efforts to reduce adverse maternal outcomes must focus on the early recognition and
treatment of PPH.

Definition and diagnosis

The most commonly accepted definition of PPH is based on the amount of blood lost after birth. In 1990, a
technical working group of the World Health Organization (WHO) defined PPH as blood loss of 500 mL from the
genital tract after vaginal delivery.8 Despite WHO’s statement in the same report that this blood loss threshold might
not be clinically significant given the lack of supporting evidence, 500 mL was selected as the volume of blood loss
for PPH diagnosis based on the customarily used cutoff and what was considered as normal postpartum blood loss. 8
Studies preceding the 1990 WHO definition of PPH that measured blood loss with the gold standard spectro-
metric and labelled erythrocyte methods found an average blood loss of 300e550 mL for vaginal delivery and
500e1100 mL for cesarean delivery.9-14 However, the sample sizes in these studies were very small (n <123) and
limited to hospital deliveries.
The most recent WHO definitions of PPH (2012) reflect the 1990 definition. For vaginal births, PPH is
defined as blood loss >500 mL,15,16 and severe PPH is defined as loss of >1000 mL. In cases of cesarean birth, the
standard for PPH is raised to 1000 mL in some guidelines. 17 Other protocols use different definitions (Table 1).17-23
Nevertheless, recent and more robust studies confirm the great variability in measured blood loss that range from
<150 mL to almost 700 mL for uncomplicated vaginal delivery,24-26 which challenges the clinical relevance of a
particular blood loss threshold.
Furthermore, blood loss thresholds may not adequately represent risk of poor outcome. The different PPH
definitions by delivery method are even more confusing: why would a blood loss of 500 mL represent a risk for
women after vaginal delivery but not for a cesarean delivery? In addition to the wide range of normal postpartum
blood loss values, the arbitrary cutoff lacks clinical accuracy.
Many women will lose >500 mL without any clinical consequence, and some will bleed less and will still be
at risk of adverse outcome.27,28 A woman’s baseline health may be an important determinant of her ability to tolerate
blood loss of any volume. For instance, most healthy nonanemic women will not exhibit signs and symptoms of
hemodynamic instability until blood loss reaches 1000 mL. 13,14,24,29 In a healthy population, this quantity of blood
loss will even be considered as physiologic and may not trigger any intervention. In contrast, for women whose
organ systems are compromised by a comorbidity, earlier intervention may be required at a lower blood loss volume
to avoid poor end organ perfusion.
No high quality evidence exists to support the current definition of PPH based on the amount of blood loss.
Furthermore, reliable measurement of blood loss presents a significant challenge for blood loss threshold based
diagnosis. The WHO recommends visual estimation of blood loss as the standard for blood loss measurement; 30 yet,
visual estimation is known to be highly unreliable. 31,32 Visual estimation of postpartum blood loss compared with
spectrophotometry underestimates blood loss by 33e50%,17,31,32 thus possibly delaying both recognition and
treatment.
A variety of blood loss measurement techniques have been used in clinical practice to improve measurement
validity, such as the under buttocks drape with a graduated/calibrated pouch.9,17,33-35 Other efforts to improve validity
include low cost strategies such as absorbent delivery mats or soaking of common household cloths. 36,37 When blood
loss is recorded by direct measurement techniques, there is a higher mean blood loss (difference, 58.6 mL) and
almost twice as many women are identified with PPH than by indirect measurement.38 However, there is no
evaluation method that is used broadly for precise blood loss measurement.
In an attempt to improve the quantification of blood loss after delivery, a movement has begun in high
resource settings to measure blood loss compre-hensively after delivery with the use of a drape and by weighing all
compresses and sponges, not only after vaginal deliveries but also after cesarean deliveries. Although this practice
results in improved accuracy of blood loss mea-surement, it is limited by the utility of blood loss volume in the
diagnosis of PPH; women experience PPH differentially at similar levels of blood loss, with some women losing
large amounts of blood without entering into a life threatening situation.
Furthermore, a more accurate assessment of blood loss alone has not been shown to improve the provision of
PPH care. A large randomized cluster trial conducted in 78 hospitals across Europe that compared visual estimation
of blood loss after delivery to objective assessment with the use of a calibrated receptacle revealed that rates of
severe PPH and the provision of additional interventions did not differ substantially between the 2 methods of blood
loss assessment.39
There is also recognition of the importance of the consideration of clinical status; in fact, most
guidelines include the recognition of changes in clinical status as part of the classification of PPH severity.
Measureable components include heart rate, arterial blood pressure, respiratory rate, and even the speed of blood
flow. Together with the amount of blood loss, clinical conditions could offer a more reliable picture of what is
happening within the cardiovascular system of the bleeding woman. Many clinical guidelines include vital signs in
the definitions and diagnosis of PPH16,17 without specifying which clinical signs are important. Most guidelines refer
to hemodynamic instability or evidence of clinical shock as the triggers for intervention. 16
The WHO working group that established the 500 mL cut off for defining PPH also concurred that PPH
diagnosis is a clinical decision thus, clinicians may decide to initiate therapeutic action at a lower level of blood loss
than 500 mL.8 In another technical report by WHO in the mid-1990s, it was further clarified that “the 500 mL limit
as defined by WHO should be considered an alert line; the action line is then reached when vital functions of the
woman are endangered.”40 Although giving the clinician considerable freedom to manage each individual patient’s
course, these proposals regarding how the 500 mL threshold could be used in practice have generated uncertainty
about when to intervene. An imprecise diagnostic threshold makes guideline and protocol development difficult.
An additional challenge is when to consider a postpartum woman as showing “evidence of clinical shock” or
“hemodynamic instability.” Some authors have proposed classification models to trigger treatment for PPH (Table
2).28,29,41 However, these systems mainly rely on estimated blood loss and therefore have the same problems as the
definitions of WHO described earlier.
In the nonobstetric population, the definition of hypovolemic shock is under discussion. Studies have found
that higher blood pressure than once previously thought can still be associated with adverse outcomes in trauma
patients. Changes in clinical signs during bleeding do not correlate with the amount of blood lost as proposed by the
traditional classifications of hypovolemic shock for trauma populations. 42 Some authors have proposed that
hypotension should be redefined with a higher cut off of blood pressure.43-45
In postpartum women, consideration of clinical signs for triggering PPH treatment should rest on a clear
understanding of the cardiovascular system during pregnancy. Changes in the cardiovascular system may be
protective for most women with hemorrhage because the adaptation of the cardiovascular system helps to
compensate for the loss of blood after birth.
 Briefly, cardiovascular changes begin around the sixth week of pregnancy, produce an increase in blood
volume of 45% (1200e1600 mL), and reach a maximum volume of 4700e5200 mL at approximately 32 weeks
gestation.46,47 Cardiac output increases by approximately 50% during pregnancy that ranges from 4.6 L/min to 8.7
L/min on average and reaches its peak between 25 and 35 weeks of gestation, after which it remains stable until
delivery. The heart rate increases from the fifth week of gestation and is up to 15e20 beats/min higher at
approximately 32 weeks gestation. Both systolic and dia-stolic blood pressures fall from 12e14 weeks gestation
onwards, which is caused by the reduction in peripheral resistance because of placental circulation bypass. From the
week 24 of gestation until birth, there is a gradual return of blood pressure to prepregnancy levels or higher because
of increased blood volume.47,48
During labor, uterine contractions, pain, anxiety, and the Valsalva maneuver promote an increase in
sympathetic tone, which raises heart rate and blood pressure. In addition, there is an increase in preload, which
changes the stroke volume and results in a 30% higher cardiac output. Immediately after childbirth, there is a rise of
60e80% in cardiac output because of the transfer of blood from the uterus into the circulatory system and because of
the increase in venous flow. These changes diminish after the first 10 minutes, approaching normal approximately 1
hour after delivery. The cardiac output decreases by one third within 2 weeks after delivery and is expected to return
to nonpregnant values after 24 weeks.46,47
In healthy pregnant and postpartum women, physiologic compensatory mechanisms prevent changes in vital
signs until a large amount of blood has been lost (usually >1000 mL).17,47 Hence, changes in vital signs that result
from hemorrhage appear late in the process and may not lead to early identification of PPH.28
In the obstetric population, there is substantial variability in the changes in clinical signs that are associated
with blood loss, which makes it difficult to establish cutoff points to trigger clinical interventions. 49 Moreover,
because traditional vital signs change late and are less reliable as triggers for clinical actions, other indicators could
help to characterize maternal hypovolemia caused by bleeding, which include the requirement for blood transfusion,
the rate of blood loss, and the decrease in hematocrit value. However, none of these has improved the identification
of PPH consistently or helped trigger action.28 Blood transfusion varies according to supply, the judgment of
individual clinicians and patient acceptance, other parameters that include the rate of blood loss and hematocrit
value may not represent the woman’s current clinical status because they are often determined retrospectively, can
be influenced by other factors, and may not be available in all settings. 50,51

New insights: the shock index

Although the use of conventional individual vital signs (pulse and systolic blood pressure) may lack accuracy
in the assessment of hypotension, a simple combination of them may transform apparently routine clinical
parameters into a more accurate indicator of hypovolemia, called the shock index (SI). The SI is calculated by
dividing heart rate by systolic blood pressure and may improve the predictive capability of individual clinical signs,
which aids early identification of women at risk of hypovolemia as the result of obstetric causes. 49
The SI was first used in 1967 to identify hypovolemic shock among patients after acute gastrointestinal
hemorrhage.52-54 There is an inverse relationship between the SI and left ventricular function that is related to the
severity of reduction in systemic blood flow and oxygen transport.54,55 In the trauma population, the SI has been
shown to be a good predictor of death.56-58 In obstetric populations, the SI was first used to identify the severity of
blood loss in ectopic pregnancy.59
Studies found the SI to be a valid indicator of blood loss in the first trimester of pregnancy for patients with
abdominal pain and a better indicator of ruptured ectopic pregnancy and hemoperitoneum than other clinical signs.59-
63
However, blood loss that occurs in the first trimester of pregnancy may trigger a different cardiovascular response
than blood loss in the postpartum period. Although this clinical sign may be valid for this population, its reliability
for postpartum blood loss is yet to be determined.
Although the SI is not a new indicator that represents severity of condition among trauma patients, its use in
the obstetric population is recent. This may be due to the cardiovascular physiologic changes during pregnancy,
which reduce the accuracy of clinical signs to identify bleeding during the pregnancy puerperal period. Renewed
attention to the role of vital signs in the evaluation of PPH followed the more recent publication of studies that relate
SI to severe hemorrhagic conditions.
Recent studies have shown a direct relationship between elevated SI and the need for blood transfusion in
term obstetric populations,64,65 which indicates that the SI might be a useful tool for the identification of severe PPH.
Le Bas et al65 also found that an SI >0.9 indicated the need for massive transfusion in PPH patients. Previous
research has identified the normal range of SI to be 0.5e0.7 in the nonpregnant population and 0.66e0.75 in early
postpartum women.65,66 A recent study established standard reference values for the SI for low risk pregnancy. The
authors found that the mean SI values ranged from 0.75e0.83 in pregnancy across all gestational ages.
The mean values decreased towards the end of gestation; for women at >37 weeks gestation, the mean SI
value was 0.79.67 For term pregnancies, an SI of 0.9 represents the 82th percentile. For postpartum women, the SI
might be slightly different, ranging from 0.52e0.89, and may be influenced by the use of epidural anesthesia and
ergometrine in the third stage of labor.66 This fact indicates that almost 20% of women without cardiovascular
problems at term or in the postpartum period would have an SI of >0.9. Therefore, although 1 isolated assessment of
the SI might be important, changes in the SI during labor and the postpartum period (ie, a trend in an upward
direction) might be a better indicator of acute cardiovascular alterations or an imminent crisis. Such changes in the
SI can be noted even before significant changes in blood pressure and heart rate occur.
In a retrospective analysis of 958 women who experienced hypovolemic shock because of obstetric
hemorrhage of all causes, the authors found the SI to be a better predictor of death and severe adverse maternal
outcomes (death or severe morbidity) than other vital signs, 68 and only 6.3% of those women had an SI <0.9 at the
time of study admission.
An additional retrospective observational study of women with PPH showed that, among the vital signs
assessed, the SI had best accuracy for adverse maternal outcomes. The cut off of 0.9 for SI for maternal death,
severe end organ failure maternal morbidity, intensive care unit admission, and other adverse maternal outcomes
showed high sensitivity and negative predictive value; however, the clinical utility of this threshold is limited by its
low specificity. SI values above the 1.7 threshold had high specificity and negative predictive value, with better
clinical applicability.69
Considering the changes in cardiovascular response at the end of pregnancy, the SI appears to be useful in
helping to detect shock. The focal point is that there may be clinical signs that could help the diagnose PPH and SI
appears to be 1 of the best hints. It is simple to calculate for most facilities and providers, and its use could be
refined to make it even simpler. For instance, if using an SI >0.9, providers in the field who might have difficulty
with division calculations could be told that, if the heart rate is higher than systolic blood pressure (thus giving a
number >0.9), the postpartum woman probably needs referral or intervention.70 However, further evaluation of the
SI is necessary to determine its utility as an early indicator of compromise among the obstetric population.

Comment
The current definition of PPH, which relies solely on the amount of blood lost, may not fit clinical needs.
We agree with the recent discussion about the need to redefine PPH.17,71 Neither the visual estimation of blood loss
nor the use of single vital signs has proved helpful in our quest to recognize PPH early and to treat it promptly.
Finding a strategy that will trigger earlier actions among women who are at highest risk of adverse outcome remains
crucial to the improvement of maternal outcomes. In settings with few PPH treatment options and many home
deliveries, diagnosis and treatment/referral must be even earlier than in hospital settings to improve outcomes.
Earlier action for women who are most at risk of adverse outcome is necessary; however, a balance is also required
to avoid unnecessarily overburdening healthcare systems.
The criteria for recognizing PPH should be simple and easy to use in everyday clinical practice in all settings
and should include clinical findings to facilitate prompt diagnosis and treatment and the early identification of
women who are likely to experience shock. Preliminary evidence suggests that the SI may be 1 such indicator
because it may have better predictive ability than other vital signs, may show changes in the maternal cardiovascular
system, and may be simple to use. Nevertheless, the predictive ability of the SI and other clinical indicators to
trigger timely treatment of PPH remains unknown but is deserving of rigorous prospective assessment.
Nevertheless, the predictive ability of the SI and other clinical indicators to trigger timely treatment of PPH
remains unknown but is deserving of rigorous prospective assessment, as well as other clinical aspects of postpartum
women that make the clinical judgment of PPH possible. Studies on the rate of blood loss, the percentage of blood
volume lost during childbirth, prospective studies on clinical signs its relation to organ perfusion, and the physiology
of postpartum bleeding, which includes dynamic effect of interventions on the cardiovascular system, may help us to
diagnose PPH more accurately.

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