This study was carried out in MVJ Medical College and Research Hospital which is a tertiary care hospital in rural Bangalore, India. After obtaining the institutional ethical committee’s clearance, written informed consents were taken from all the women/ family members in case of MMR. A retrospective analysis of all the women with PPH (within the first 24 hrs of their deliveries) during a period of 4 consecutive years (2008 to 2012), was done by the same person. The PPH in the institute was measured both objectively and subjectively, i.e., any amount of blood loss following birth, that adversely affected the mother as well as a loss of > 500 ml in vaginal deliveries and of > 1000 ml during caesarean sections (which were estimated from the use of sponges and the blood in suction by the attending staff). Mild PPH blood loss is 500ml to 700ml, moderate PPH blood loss is 700ml to 1000ml and severe PPH blood loss is more than 1000ml. The criteria for the diagnosis of the deliveries which had taken place outside the institute was not clear, but since they were referred with a diagnosis of PPH from outside and as most of them were in a moribund state, no exact definition was sought from them. Such women were identified from the labour record registers and then all the case sheets were reviewed and the demographic variables of age, parity, the period of gestation and the mode of the delivery were noted. The cause of the PPH and the medical or surgical interventions were analyzed. A morbidity assessment was done and the “near-miss” morbidity was identified by using the scoring system which was outlined by Geller et al. [16,17].

A “near-miss” morbidity is considered as a sensitive indicator of the assessment [18]. In this system, five clinical factors - organ failure (³ 1 system), extended intubation (³12 h), ICU admission, surgical intervention and transfusion (³3 units) are – grouped into a scoring system. The total score is calculated as the weighted sum of the clinical factors which are present for each woman. This scoring system has a specificity of 93.9%. The total score was calculated as the weighted sum of the clinical factors which were present for each woman, with a score of ³8 being considered as a “near-miss” morbidity. In our hospital, the active management of the 3rd stage, in the form of intramuscular ergometrine at delivery, of the anterior shoulder or 10-20 units of oxytocin infusion in 500 ml of normal saline and a controlled cord traction are practised routinely. A note was made of similar practices which were carried out outside.

During the study period, a total of 5600 women delivered in our hospital. Of these, 60 had PPH (with an incidence of 1.07%). In addition, 64 women were referred from peripheral health centres with PPH. Thus, we had a total of 124 women with PPH for analysis. The mean age of the women was 26 years and the mean gestational age at delivery was 37.6 weeks. About half of the women (48%) were primiparous and the pregnancies had been supervised only in about one-fourth of the women (26.4%). The onset of labour was spontaneous in 50.6% women and 65.7% had delivered vaginally. For the purpose of the analysis, we divided the women with PPH into two groups - Group A (the women who delivered in this hospital, n=60) and Group B (the women who were referred after having delivered elsewhere n=64).

[Table/Fig-1] shows the labour characteristics and the causes of PPH in the two groups. In our hospital, the active management of the 3rd stage is practised routinely. However, the routine active management of the 3rd stage, though it was recommended by the WHO, was practised in only 50% of the women in Group B. This fact may be responsible for the finding that though uterine atony had emerged as the leading cause of PPH in both the groups, it was significantly higher (almost double) in those who had delivered elsewhere and had been referred to this hospital with PPH. The atonicity in group B was also contributed to by the retained placental tissue and the uterine inversion, thus highlighting the need for proper delivery techniques. In a majority of the women (80%), excessive bleeding had occurred within 6 hours of their deliveries. However, a majority (53.4%) of the women who had delivered elsewhere had reached our hospital after 6 hours, thus losing precious time.

The frequency and the severity of the complications were more in group B. Amongst the injuries, lower genital tract trauma was significantly more in the hospital deliveries, but uterine rupture was more in the referred group (although it was not statistically significant).

[Table/Fig-2] shows the overall morbidity and the mortality data. There was a total of 4 deaths among the 124 women with PPH (with a mortality rate of 3.2%). During the study period, there were 5600 live births at our hospital . The maternal mortality ratio during this period was 71/100,000 (4 maternal deaths/5600 live births). Between the two groups, all the deaths were among the women who had delivered elsewhere and had been referred with PPH,. Thus, though the overall mortality was not significantly different, a majority of the deaths in Group B were associated with multiple organ failure, which is an indirect indicator of the delay in the initiation of the treatment.

An attempt to analyze the “near-miss” morbidity (the cases that could easily have progressed to mortality) was made, in order to identify the factors that could trigger events that could ultimately lead to maternal mortality. 32 women (25.8%) suffered a “near-miss” morbidity. The causes for the “near-miss” morbidity in the women who delivered in our hospital (Group A) were uterine atony (4 cases), followed by retained placentae (3 cases) and cervical lacerations (1 case). Amongst the referred cases (Group B), uterine atony, retained placentae and ruptured uteri accounted for 7, 13 and 4 cases respectively. Amongst the 32 women, the major group comprised of referral patients. A delayed referral (a transfer time of > 6 hours after the delivery) was observed in Group B in 50/64 (78 %) women and all the 32 women who had the “near-miss” morbidity had reached our hospital at > 6 hours after their deliveries.

Although a score of ³8 was taken as the cutoff for the near-miss morbidity evaluation, as shown in [Table/Fig-2], the individual factors which were assessed were high and their impact on the quality of life could not be understated. Again, a comparison between the two groups revealed a higher rate of complications in the referred group with organ failure, which was sevenfold more, while the ICU admission, the extended intubations and the 3 units transfusion rate were fourfold more and the surgical interventions were six-fold higher than in those who had delivered in our hospital.

In [Table/Fig-3], the details of the morbidity in all the cases revealed a significantly high morbidity in all these women and again, a greater number amongst the outside deliveries, with cardiac causes (hypotension) mainly contributing to the organ system failure. The major surgical interventions which included hysterectomy and bilateral uterine artery ligation were required in more cases in Group B, thus signifying the severity of the complications in this group.

[Table/Fig-6]:

Incidence of mild, moderate and severe pph cases in Group A and Group B

[Table/Fig-7]:

Morbidity trends in Group A vs Group B: Group B having higher morbidity than Group A

Frequency of mild, moderate, severe post partum hemorrhage in group a, and group B.

The exact incidence of PPH is difficult to determine, due to the difficulty in accurately measuring the blood loses. Most of the studies have quoted figures which ranged from 5 to 12% for vaginal deliveries [19, 20].

The maternal mortality has been used traditionally as a measure of the quality of the health care. However, recently, the maternal morbidity, especially, the “near miss” morbidity, is being taken into account to assess the burden of the disease. Apparently, two-thirds of the obstetric morbidity is related to haemorrhage [17]. It has been estimated that PPH increases the risk of the morbidity 50 times and that it has 5 times higher morbidity than the mortality [20]. This study attempted to analyze the data of the women who had PPH over a 4-year period – in order to identify the causes, the mortality and the “near-miss” morbidity which were associated with it as well as the risk factors that contributed to the adverse outcomes.

An assessment of the causes of PPH revealed that the incidences of uterine atony, retained placentae and uterine inversions were significantly less among the women who had delivered at our hospital as compared to the women who had been referred with PPH after having delivered elsewhere. The regular use of an active management in the 3rd stage, as well as a prompt recognition of the complications, with the institution of the appropriate management, emerges as the obvious reason. The main causes of PPH among the hospital delivery group (Group A) were atony and retained placentae; which are not always associated with the significant morbidity for the surgical intervention [21]. The time of presentation of the PPH in Group A in a majority (87%) of the cases was within 6 hours of the delivery, which highlighted the need for a continuous vigilance postpartum and a prompt action in case of problems [6, 7].

The mortality in Group B was more than that in Group A, despite the fact that our hospital catered to a high-risk population (4 versus 0). This implies that PPH persists as a cause of mortality despite providing adequate intranatal care [21–23]. The evaluation of the causes of mortality showed that multiple organ failure was the major cause of the mortality in the referred cases and in all these cases, the underlying event was uterine atony, which emphasized the need for an active management of the labour and a prompt management of the PPH if it occurred. Such a prevention could be meaningfully achieved by the use of an active management of the 3rd stage of labour (oxytocics at the anterior shoulder, controlled cord traction and primary cord-clamping), which causes a reduction in the blood loss, postpartum anaemia, a need for transfusion and the severity of the PPH if it occurs [24][Table/Fig-4,5,6 and 7].

This study also highlighted that the mere assessment of the mortality data was not enough. The morbidity parameters are more sensitive and efficient. The incidence of morbidity was quite high in our study. A total “near-miss” morbidity incidence of 39.6% was observed in our study, which was much higher than the reported incidence of 0.05-1.2% [19,25,26]. Also, the comparison revealed that the referred cases had significantly more morbidity [Table/Fig-8 and 9]. Organ failures, ICU admissions, intubations, blood transfusions and surgical interventions were significantly higher among the referred group. The organ failures and surgical interventions had increased fourfold and six-fold respectively; while ICU admissions, extended intubations and transfusions of >3 units were two fold higher among the referred cases. This revealed that the morbidity parameters were much more sensitive and that they should be incorporated in the clinical reviews to evaluate the actual burden of the problem and to find better and effective management strategies. Overall, the hospital deliveries had better outcomes, milder courses and less severities, thus again implicating a substandard care/delayed care as significant, as was shown by other studies [27]. The significantly less morbidity and the “near-miss” cases among the hospital deliveries reflected that the prompt institution of the active 3rd stage management in all the cases had helped in reducing the complications. However, since the sample size was small, it is difficult to compare both the mortality and the morbidity amongst the hospital and the non-hospital deliveries. Fahy [27] reported that 2.6 percent of the women in their cohort study had a blood loss which was greater than 1,000 mL, and Rogers et al., [28] identified in their randomized controlled trial that 2 percent (90/3,436) of the women had a blood loss which was greater than 1,000 mL.The report of Thompson et al., [29] demonstrated that 2.3 percent of the women who gave birth vaginally had a blood loss of 1,000 mL or more but which was less than 1,500 mL and that 1.6 percent had a blood loss of 1,500 mL or more. In the present study, 40.3% of the women had a blood loss which was between 500-700 ml, 27.4% had a blood loss which was between 700-1000 ml and 32.2% had a blood loss of more than 1000ml.

[Table/Fig-8]:

Comparision of Causes of Post Partum Hemorrhage in Various Studies in India

[Table/Fig-9]:

Comparision of Causes of Postpartum Hemorrhage I Patients Delivered at our Hospitals and Those Delivered Out Side Our Hospitals Table 1

A more recent Swedish trial [4] which was done on low-risk women (although it also potentially included women who had experienced an induction or an augmentation of labour), which compared the physiological third stage with the active management, reported a high rate of severe postpartum haemorrhages—13.5 percent overall. The physiological group was significantly more likely to experience a blood loss of greater than 1,000 mL, but it was no more likely to have a blood transfusion than that of the active management group [Table/Fig-10].

[Table/Fig-10]:

Bar Chart Showing the Number of Patients Who are in Asses to Emoc at 6,6-12,12-24 Hrs

The “near-miss” morbidity score was started with the intention of evaluating the existing problem in the developed world, where the maternal mortality is on the decline; yet the same can be used to identify the load of the significant maternal morbidity in the developing countries, since it is a sensitive indicator of the pregnancy outcome [13,19–21, 24]. Most of the studies have implicated that haemorrhage contributes to 24-64.8% cases of “near-miss” obstetric morbidity and our study also showed that the “near-miss” morbidity assessment was significantly more informative than the mortality [30–34]. Therefore, its evaluation, along with the prediction of the risk factors, will reduce the disease burden and improve the health status. Similar conclusions have also been reached in other studies [19]. In conclusion, an assessment of the “near-miss” morbidity is as important as the mortality data, for evaluating the actual brunt of the disease in the developing world, where a significant morbidity assumes demonic proportions by affecting the quality of life and giving a tsunamic blow to the already staggering economy [35–37].

Postpartum haemorrhage (PPH) is an obstetrical emergency which follows a delivery. It is a major cause of maternal morbidity, and one of the top three causes of maternal mortality. Haemorrhage is the leading cause of the admissions to the intensive care unit and the most preventable cause of the maternal mortality. An efficient management of the third stage of labour can significantly reduce the need for surgical interventions in managing the post partum haemorrhage. The near miss cases can be significantly reduced by the hospitals which adopt the policies of an active management of the third stage of labour and timely referrals.