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Understanding the Risk of Hemorrhage During Childbirth

A frightening trend is taking place in the United States -- an increasing number of women are dying during or shortly after childbirth. The number of pregnancy-related deaths increased from 7.2 per 100,000 live births in 1987 to 17.8 per 100,000 live births in 2011.
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A frightening trend is taking place in the United States -- an increasing number of women are dying during or shortly after childbirth. The number of pregnancy-related deaths increased from 7.2 per 100,000 live births in 1987 to 17.8 per 100,000 live births in 2011.

The U.S. maternal death rate is increasing at the same time that other countries have had a decrease (1). While there are many factors that influence the rising death rates in the U.S., including the way we track and report data, the overwhelming evidence points to obstetric hemorrhage (or excessive bleeding) as a leading cause of these deaths (2).

Experts estimate that more than half of the deaths associated with pregnancy and birth can be prevented (3). The Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) has long been active in working to improve clinicians' recognition of, readiness for, and response to hemorrhage through the AWHONN Postpartum Hemorrhage Project. Most recently, AWHONN developed the Postpartum Hemorrhage Risk Assessment Tool to help clinicians recognize women who are at risk for hemorrhage.

The new tool identifies the low, medium, and high risk factors associated of obstetric hemorrhage upon hospital admission, pre-birth, and post-birth. It includes recommendations for how nurses, physicians, and midwives can prepare for potential interventions and treatments based on the woman's risk of hemorrhage.

Women and their families should also know the risk factors - particularly those that are within their control - for postpartum hemorrhage. Labor induction increases the risk. Before agreeing to an induction, a woman should discuss the risks and benefits with her healthcare provider. Morbid obesity can also put a woman at greater risk for hemorrhage. If possible, reaching a healthy weight before pregnancy not only reduces the risk of hemorrhage, but it also reduces the risk of defects to the infant's brain or spine, preterm delivery, diabetes, and caesarean birth.

There are other risk factors associated with hemorrhage that women may not be able to control, but that they should be aware of and inform their nurses. Examples include multiple gestation (4), more than four previous vaginal births (5), uterine fibroids (6), and history of postpartum hemorrhage (either for the woman or a close member of her family) (6).

AWHONN's new Postpartum Hemorrhage Risk Assessment Tool will be provided to over 200 hospitals that currently use the Epic Stork system later this year so that nurses and other healthcare providers can quickly and accurately track risk factors for hemorrhage, so that they can prepare interventions, as needed. Early identification of risk factors can help clinicians prevent adverse outcomes and individualize a plan of care for each woman.

Our mission at AWHONN is to promote the health of women and newborns. Understanding the risks for postpartum hemorrhage has the potential to make a significant impact in reducing the rate of maternal death in the United States.

Sources:

1) Kassebaum, N. J., Bertozzi-Villa, A., Coggeshall, M. S., Shackelford, K. A., Steiner, C., Heuton, K. R., ... Lozano, R. (2014). Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet (London, England), 384(9947), 980-1004. http://doi.org/10.1016/S0140-6736(14)60696-6

2) Berg, C. J., Callaghan, W. M., Syverson, C., & Henderson, Z. (2010). Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology, 116, 1302-1309. http://doi.org/10.1097/AOG.0b013e3181fdfb11

3) The California Pregnancy-Associated Mortality Review, Report from 2002 and 2003 Maternal Death Reviews - MO-CA-PAMR-MaternalDeathReview-2002-03.pdf. (n.d.). Retrieved January 27, 2014, from http://www.cdph.ca.gov/data/statistics/Documents/MO-CA-PAMR-MaternalDeathReview-2002-03.pdf

4) Bateman, B. T., Berman, M. F., Riley, L. E., & Leffert, L. R. (2010). The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesthesia and Analgesia, 110, 1368-1373. http://doi.org/10.1213/ANE.0b013e3181d74898

5) Silver, R. M., Landon, M. B., Rouse, D. J., Leveno, K. J., Spong, C. Y., Thom, E. A., ... National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. (2006). Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics and Gynecology, 107(6), 1226-1232. http://doi.org/10.1097/01.AOG.0000219750.79480.84

6) Oberg, A. S., Hernandez-Diaz, S., Palmsten, K., Almqvist, C., & Bateman, B. T. (2014). Patterns of recurrence of postpartum hemorrhage in a large population-based cohort. American Journal of Obstetrics and Gynecology, 210(3), 229.e1-8. http://doi.org/10.1016/j.ajog.2013.10.872