INSIGHT: Critical Issues in Global Nursing

Maternal Mortality Part I: Four Primary Causes of Postpartum Hemorrhage

More than 800 women die every day around the world from pregnancy or childbirth related complications. The INSIGHT series on Maternal Mortality was launched in February of this year to bring attention to a critical health problem that affects nursing across the globe. And while maternal mortality is higher in rural and poor resourced communities, it is not just a problem limited to developing countries as was shared in the June INSIGHT post.

Because postpartum bleeding or postpartum hemorrhage (PPH) is the leading cause of maternal deaths globally, it is important to focus on PPH creating a greater awareness around the problem, including leading causes and risk factors.

A 2014 article from the International Journal of Obstetrics and Gynecology: The prevention and treatment of postpartum hemorrhage: what do we know, and where do we go to next? noted that globally, PPH occurs about 8.7 million times and results in 44,000 to 86,000 deaths per year. In referencing developing countries, a WHO study was cited finding that about1.2% of deliveries resulted in PPH. When PPH occurred with those deliveries, about 3% of the women died.

Primary postpartum bleeding is defined as blood loss in excess of 500 ml following a vaginal delivery or 1000ml following a caesarean section within the first 24 hours post-delivery. Secondary postpartum bleeding is defined as occurring after the first 24 hours and up to six weeks after delivery.

Further detailed in A Comprehensive Textbook of Postpartum Hemorrhage 2nd Edition, larger blood loss leads to low blood volume and results in initial symptoms such as increased heart rate, feeling faint upon standing, and increased breath rate. As more blood is lost, the mother may feel cold, her blood pressure can drop and she can become restless or unconscious.

According to the Postpartum Hemorrhage: Prevention and Treatment study by the American Academy of Family Physicians, the four primary causes of PPH globally are commonly referred to the “four T’s”: Tone, Trauma, Tissue and Thrombin.

  • Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony. This is the most common cause of PPH.
  • Trauma: injury to the birth canal which includes the cervix, vagina and the perineum. This can happen even if the delivery is monitored properly. The bleeding is substantial as all these organs become more vascular during pregnancy.
  • Tissue: retention of tissue from the placenta or fetus as well as placenta accrete and percreta may lead to bleeding.
  • Thrombin: a bleeding disorder occurs when there is a failure of clotting, (coagulopathy)

Postpartum Hemorrhage – Most Common Causes

Uterine Atony
Retained Tissue

Some common risk factors that can contribute to PPH include: obesity, the mother is older than 40 years, Asian ethnicity, heart disease, anemia, fever during pregnancy, delivery of multiple babies or delivery of a baby that is larger than 8.8 pounds.

Jhpiego, an international, nonprofit health organization affiliated with The Johns Hopkins University, has developed a suite of training programs to provide healthcare workers with skills in prevention, detection and management of the leading causes of maternal deaths, including bleeding after birth. Their provider guide for Helping Mothers Survive Bleeding After Birth provides resources and key protocols that can help nurses better identify and manage life-threatening complications for mothers and babies.

Click here to view the complete module.

Next week, the INSIGHT focus on PPH will continue as innovative advances in treatment options for PPH are highlighted. Making a significant impact is the LifeWrap™ Non-Pneumatic Anti-Shock Garment, (NASG). This is a device being used worldwide to successfully treat shock, resuscitate, stabilize and prevent further bleeding in women with obstetric hemorrhage.

If you have follow-up questions or suggestions, please send and email to [email protected].  We would love to hear from you. Thank you for being a part of global nursing development!

Yours in Nursing,


Lisa D. Cole, MA, RN

Director, Mary K Center for Global Nursing Development