A C TA Obstetricia et Gynecologica

A CTA OVERVI E W

Postpartum hemorrhage update on problems

of definitions and diagnosis
WERNER H. RATH
Faculty of Medicine, University Hospital RWTH Aachen, Division of Obstetrics and Gynecology, Aachen, Germany

Key words Abstract

Postpartum hemorrhage, mortality,
measurement of blood loss, definitions,
diagnosis
Correspondence
Werner H. Rath, Faculty of Medicine,
University Hospital RWTH Aachen,
Wendlingweg 2, D-52074 Aachen, Germany.
E-mail: wrath@ukaachen.de
Conflict of interest
The author has stated explicitly that there are
no conflicts of interest in connection with this
article. The author alone is responsible for the
content and writing of the paper.
Received: 21 January 2011
Accepted: 30 January 2011
DOI: 10.1111/j.1600-0412.2011.01107.x
Maternal mortality due to postpartum hemorrhage (PPH) continues to be one of
the most important causes of maternal death worldwide. PPH is a significantly
underestimated obstetric problem, primarily because a lack of definition and diag-
nosis. The traditional definition of primary PPH based on quantification of blood
loss has several limitations. Notoriously, blood loss is not measured or is signif-
icantly underestimated by visual estimation and there are no generally accepted
cut-offs limits for estimated blood loss. A definition based on hematocrit change is
not clinically useful in an emergency such as PPH, as a fall in hematocrit postpartum
shows poor correlation with acute blood loss. The need for erythrocyte transfusion
alone to define PPH is also of limited value, as the practice of blood transfusion
varies widely. Definitions based on symptoms of hemodynamic instability are prob-
lematic, as they are late signs of depleted blood volume and commencing failure of
compensatory mechanisms threatening the mothers life. There is thus currently no
single, satisfactory definition of primary PPH. Proper and timely diagnosis of PPH
should above all include accurate estimation of blood loss before vital signs change.
Estimation of blood loss by calibrated bags has been shown to be significantly
more accurate than visual estimation at vaginal delivery. Careful monitoring of the
mothers vital signs, laboratory tests, in particular coagulation testing, and imme-
diate diagnosis of the cause of PPH are important key factors to reduce maternal
morbidity and mortality.

Abbreviations PPH, postpartum hemorrhage

are due to immediate PPH (3). However, a high number of

Introduction
An estimated 14 million cases of postpartum hemorrhage
(PPH) occur each year worldwide with a case-fatality rate
of 1% (1); one woman dies every 4 minutes from PPH (2).
Obstetric hemorrhage has been estimated to cause 25% of
all maternal deaths and nearly half of postpartum deaths
unreported cases must be taken into account, and the true
incidence of maternal deaths due to PPH is certainly much
higher.
The absolute risk of death is much lower in high-income
countries with an estimated rate of 1:100 000 deliveries as
compared to an estimated rate of 1:1 000 in low-income
countries (4).
A recent WHO analysis of causes of maternal deaths re-

ported a wide variation in the incidence of maternal deaths

Statement: An earlier version of this article was published in
German under the title Definition und Diagnostik postpar-
taler Blutungen (PPH): Unterschatzte Probleme!/ Definitions
and Diagnosis of Postpartum Haemorrhage (PPH): Underesti-
mated Problems! in Geburtsh Frauenheilk 2010; 70 (1): 36-40;
DOI:10.1055/s-0029-1240719. Copyright Georg Thieme Verlag
KG. Thieme publishers have kindly given permission to the publi-
cation of this revised article in English.
due to obstetric hemorrhage, which is the single most im-
portant cause of both maternal mortality and morbidity. In
high-income countries, hemorrhage, mainly due to PPH, is
responsible for 13.4% of maternal deaths, whereas it accounts
for 34 and 30.8% in Africa and Asia, respectively (3).
Decreasing the prevalence of severe PPH remains a chal-
lenge. Individual risk factors have been demonstrated in 40%


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C 2011 Nordic Federation of Societies of Obstetrics and Gynecology 90 (2011) 421428 421
Postpartum hemorrhage - definitions and diagnosis W.H. Rath

Table 1. Major problems in risk management of primary postpartum hemorrhage (PPH).

Misdiagnosis or Lack of consensus in terms of PPH definition

delay in diagnosis Underestimation of the speed and extent of hemorrhage
Lack of local ease-to-use action plans (protocols)
Lack of adequate education and training


Failures in treatment such as: Too little is
inadequate use of oxytocics (or not available) done too late!

delay in blood transfusion/coagulation factors (or not available)
ignoring the results of basic monitoring
inadequate senior input decision-making failures

Deficiences in the
such as: lack of staff and appropriate equipment, ineffective teamwork, coordination,
organization (systems failure)
communication and interdisciplinary cooperation

Collated from information from Upadhyay & Scholefield (2008) (14).

of women who develop PPH, but they are poor predictors of
the occurrence of PPH (5). Interest has focused on care pro-
cedures, as they are potentially amenable to change. Previous
studies on maternal deaths have shown that most deaths due
to PPH involve delayed and substandard care in the diagnosis
and management of blood loss (6,7). Similar findings were
drawn from a population-based study of severe non-lethal
PPH (8). The prevalence of PPH (defined as 500ml blood
loss) and severe PPH (defined as 1 000ml blood loss) is ap-
proximately 6 and 1.86% of all deliveries, respectively, with a
wide variation across regions of the world (9).
Severe hemorrhage is also the most common cause of se-
rious maternal morbidity, including adult respiratory dis-
tress syndrome, renal failure, coagulopathy, shock, myocar-
dial ischemia, hysterectomy, and long-term morbidity such
as anemia, which can be a serious clinical problem, especially
in low-income countries. Approximately 20 million women
worldwide suffer from acute or chronic disability following
immediate PPH each year (2). Severe maternal morbidity due
to PPH has been estimated at 4.56.7/1 000 deliveries (10,11).
Interestingly, recently published population-based studies of
severe maternal morbidity demonstrate that the rate of PPH
and related serious maternal problems has significantly in-
creased in some high-income countries (12,13).
The major problems in risk management of PPH are shown
in Table 1. Delay in diagnosis and treatment of PPH may re-
sult from the lack of consensus in terms of its definition and
underestimation of blood loss at delivery, failure of adequate
management, poor communication, and deficiencies in orga-
nization (14). However, even with appropriate management,
approximately 3% of vaginal deliveries will followed by severe
PPH (15).
Material and methods
Electronic searches were performed in the Medline database
using the key word postpartum hemorrhage in combination
with definitions, diagnosis, and measurement of blood loss.
Approximately 2 600 English-language articles from January
1990 to June 2010 were identified using the key word post-
partum hemorrhage. The search was then focused on the
other key words outlined above. Case reports were deleted.
Studies selected were mainly published in the last 10 years,
but frequently referenced and highly regarded older reports
were not excluded.
Reference lists of articles identified by this strategy were
also searched and articles referring to the key words were se-
lected. In addition, relevant chapters of textbooks and current
guidelines were examined to capture any further information
or additional reports not identified in the electronic search.
Finally, 125 publications were judged relevant and 56 were
included in this overview. The vast majority of studies are
cohort studies, case-control studies or case series examining
the measurement of blood loss associated with PPH. Thus,
the level of evidence based on the classification of the Oxford
Centre of Evidence-Based Medicine is mainly II, III, or IV.
Results
Definitions of PPH and related problems
Proper definition of PPH should be standardized, simple,
and appropriate for use in everyday obstetrical practice, not
only in high- but also low-income countries; it should take
into consideration both the volume loss and the clinical con-
sequences of such loss. The recorded parameters should be

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W.H. Rath
easily measurable and reproducible and the ideal definition
should facilitate prompt diagnosis and adequate treatment
(16). The definition of PPH should also be considered in the
light of recent advances in anesthesia, resuscitation therapy,
new drugs, active management of the third stage of labor, and
improvement in surgical procedures.
It is generally accepted to classify PPH as primary (within
the first 24 hours of delivery) and secondary (more than
24 hours after delivery but less than 12 weeks). Otherwise
there has been no significant change in the definition of PPH
over the past 50 years, and there is currently no single, sat-
isfactory definition of primary PPH. The most commonly
used (traditional) definition that was proposed by the World
Health Organization in 1990 is any blood loss from the gen-
ital tract during delivery above 500ml (17). This is a volume
that, when left untreated, may be sufficient to cause hemor-
rhagic shock and death in some instances (18). Traditionally,
PPH following a cesarean section has been defined as blood
loss in excess of 1 000ml (19). These definitions are based
on quantification of blood loss originated from historical
studies published in the early 1960s.
Using photometric methods or radioactive chromium-
tagged red blood cell techniques, the average blood loss
was found to be 300550ml after vaginal delivery (20,21),
and 5001 100ml after a cesarean birth (21,22); 23% of
cesarean deliveries were associated with blood loss of
between 1 0001 500ml, and 8% with a loss above 1 500ml
(21). Another study showed that up to 16% of vaginal and
30% of operative vaginal deliveries may be associated with
blood loss greater than 500ml (23). Using radioisotope
dilution techniques, the mean blood loss for first elective
cesarean section was found to be 1 290 (240ml), which is
significantly more than the estimated blood loss recorded by
most obstetricians (24).
Thus, the traditional definition of primary PPH is in
reality a reflection of the almost universal tendency to under-
estimate delivery blood loss.
On the other hand, clinical measurements of blood loss
have clearly demonstrated that the average blood loss at vagi-
nal and cesarean delivery frequently exceeds 500 and 1 000ml,
respectively (25). Table 2 gives an overview on currently used
definitions of PPH based on quantification of blood loss and
the impact of this on various clinical guidelines. While some
guidelines acknowledge the traditional definition (26,27),
others advocate alternative cut-off values for blood loss or a
combination of both estimated blood loss and clinical signs
of hypovolemic shock (2830). Many authors have criticized
relying on a definition solely based on the amount of blood
loss without consideration of clinical signs and symptoms, as
this may lead to inconsistency in management (16,31).
It is also a matter of debate whether the traditional defini-
tion is clinically appropriate regarding the amount of blood
loss, and whether it should be revised to identify a group of

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Postpartum hemorrhage - definitions and diagnosis
Table 2. Definitions of postpartum hemorrhage (PPH) based on quan-
tification of blood loss and its use in guidelines.
Traditional definition:
blood loss > 500 ml following a vaginal delivery (17)
blood loss > 1000 ml following a cesarean section (19)
ACOG 2006 (26): no single, satisfactory definition
Australia (ICD10-AM) 2008 (28):
Blood loss > 500 ml after vaginal delivery and > 750 mL after
a caesarean section
German Guidelines 2008 (27): see traditional definition
Austrian Guidelines 2008 (29):
Blood loss of 5001000 ml and clinical signs of hypovolemic shock
shock or blood loss > 1000 ml
RCOG 2009 (30): blood loss of 5001000 ml in the absence of
clinical signs of shock
major PPH: blood loss >
moderate 10002000 mL
1000 mL
severe > 2000 mL
women who become ill and are at real risk of severe mor-
bidity after the hemorrhage (32). Consequently, it has been
proposed that it may be better to think of the term major or
severe PPH, using a definition of loss of more than 1 000ml
or more than 1 500ml, rather than defining primary PPH as
>500ml blood loss (32). However, it should be kept in mind
that a blood loss of 1 500ml reflects the point when physio-
logical compensatory mechanisms begin to fail. A generally
accepted definition of PPH should not neglect the conditions
and circumstances in low-income countries, where women
are likely to be severely anemic prior to delivery, and to have
co-morbidities such as malaria and experience limited access
to treatment facilities (33).
While healthy women can usually tolerate acute blood loss
of up to 1 000ml or more without significant hemodynamic
problems (34), this is certainly not the case in severely ane-
mic women. Anemia has been estimated to affect half of all
pregnant women in the world. In severely anemic women a
mere 250ml blood loss might result in the same adverse clin-
ical outcome as the loss of a larger volume in women with a
normal hemoglobin value (35). The most important limita-
tion of definitions based on cut-offs of estimated blood loss is
that frequently blood loss is not measured or is significantly
underestimated by visual estimation (25). These inaccuracies
may lead to a delay in diagnosis and treatment of PPH, re-
sulting in preventable adverse outcomes. Visual assessment
has been shown to underestimate postpartum blood loss by
3350% compared to the gold standard photospectrometry
(36,37).
Comparing visual estimation with direct measurement of
blood loss at vaginal delivery, the incidence of PPH was 5.7
and 27.6%, respectively, which corresponded to an underes-
timation of the incidence of PPH with visual estimation by
nearly 90% (38). A similar degree of underestimation was
reported by Razvi et al. (39). Several authors have confirmed
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Postpartum hemorrhage - definitions and diagnosis
medical practitioners inaccuracy in estimating blood loss
at cesarean deliveries. Some found underestimation to be
common, others overestimation, and still others found in-
consistencies but without any particular pattern (4043). A
recent study from Dallas (USA) compared visual estimation
with calculated blood loss at vaginal and cesarean delivery;
calculated blood loss was determined by a modified version
of a calculation for pregnancy blood volume. The visual esti-
mation was less than half the calculated measurement during
operative vaginal births and more than a third in vaginal
births associated with third- and fourth-degree lacerations.
The tendency to underestimate was greatest with a calcu-
lated loss of >1 000ml; for example, of the 90 cesarean de-
liveries with calculated blood loss greater than 1 000ml, only
18% of them were correctly estimated (42). The message
from the majority of studies was that the higher the mea-
sured blood loss, the greater the underestimation by visual
assessment (36,39,44). Blood loss was found to be overesti-
mated at low volumes (<150250ml). This applies also to
blood loss at cesarean section (41).
Intraoperative blood loss measured by the alkaline hematin
method during elective lower segment cesarean section was
approximately 500ml and did not differ significantly from
visually estimated blood loss; however, observer error in es-
timated blood loss was higher if a measured loss exceeded
600ml (36). This finding was in accordance with a previous
study of the accuracy of blood loss estimated by midwives at
a simulated birth (45).
In daily obstetric practice, hidden loss in linen, swabs, pads
and so on, or hidden loss under the drapes at cesarean section,
or in a slow, steady trickle, are common reasons for under-
estimation. In addition, contamination with amniotic fluid,
urine or other fluids may mask the real amount of blood loss.
When using an underbuttocks drape with a graduated pouch
for measurement and calculating blood loss by direct weigh-
ing of all blood-soaked sponges, the amount of contaminant
in the pouch ranged between 4 and 81% of the total fluid
collected (46). This wide variation in the amount of contam-
inant illustrates the major limitations of direct measurement
or weighing blood loss. Weight does not discriminate between
blood and other types of fluid and gravimetric methods re-
quiring the weighing of all materials may take many hours to
complete (46).
In a recent study, participants were randomized to estimate
simulated blood loss in calibrated or noncalibrated delivery
drapes, which also contained 100ml of urine and sponges.
Visual estimation with noncalibrated drapes underestimated
blood loss, with worsening accuracy at large volumes, such
as 16% error at 300ml up to 41% at 2 000ml. The cali-
brated drape error was <12% at all volumes (47). The total
amount of blood loss can also be difficult to assess because of
concealed bleeding within the uterine cavity, into the broad
ligament, the peritoneal cavity or retroperitoneal space.
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Finally, it has been criticized that these definitions do not
consider the rapidity of blood loss, which better correlates
with hemodynamic changes and has a considerable impact
on severe maternal morbidity (16). In attempts to overcome
these inconsistencies, postpartum hemorrhage has been de-
fined as either a 10% change in hematocrit between admis-
sion and the postpartum period or a need for erythrocyte
transfusion (48).
Nearly 20 years ago, Combs et al. (48) pointed out that
a definition of PPH based on hematocrit change has several
advantages: it is objective and relatively precise, admission
and postpartum hematocrit are routinely and simply deter-
mined; hematocrit is a clinically relevant variable often used
in decision-making regarding the need for transfusion; and
hematocrit change is affected not only by hemorrhage in the
delivery room but also by delayed hemorrhage. Postpartum
hematocrit change following vaginal delivery has been shown
to have a significant negative nonlinear correlation with vi-
sually estimated blood loss (49).
However, a definition based on hematocrit change is not
clinically useful in an emergency such as PPH for several rea-
sons: acute blood loss is mostly not reflected by a decrease
in hematocrit or hemoglobin concentration for four hours
or more, and the peak drop may be appreciated on day 2
or 3 postpartum (50). Thus, rapid blood loss may trigger a
medical emergency prior to observation of a fall in hema-
tocrit concentration. Previous studies have shown a weak
association between measured acute blood loss and decline
of postpartum hematocrit or hemoglobin (43,50,51). There-
fore, laboratory changes that are not correlated with events
that endanger the patient should not be used to define a
medical emergency (31).
Furthermore, the change in hematocrit depends on the
time of testing and the amount of fluid resuscitation previ-
ously administered, and could also be affected by prepartum
hemoconcentration, e.g. in patients with preeclampsia or de-
hydration.
Definitions based on the need for erythrocyte transfusion
alone are also of limited value as the practice of blood trans-
fusion varies widely according to local circumstances and
attitudes to transfusion among both patients and physicians.
The speed of estimated blood loss, the peripartal drop
of hemoglobin, and the number of erythrocyte transfusions
have been proposed to define severe PPH (Table 3; 52); how-
ever, all definitions are of limited clinical value for the reasons
mentioned above. Other authors have suggested abandoning
altogether numerical assessments and instead defining PPH
as any excessive bleeding resulting in signs and symptoms
of blood loss (33). This is the merit of John Bonnar, who
characterized the clinical signs and symptoms related to the
volume of blood loss (52).
As a consequence of increased circulating blood volume
during pregnancy, vital signs of hypovolemic shock become
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W.H. Rath
Table 3. Definitions of severe postpartum hemorrhage (PPH).
transfusion 4units of blood
blood loss of 50% of the circulating blood volume in less than
three hours
blood loss > 150ml/minute within 20 minutes (50% blood volume)
peripartal drop of hemoglobin concentration of 40g/l
sudden blood loss > 1500ml (25% of the blood volume)
Collated from information from Bonnar (2000) (52).
relatively insensitive in pregnancy. Tachycardia does not usu-
ally develop until blood loss exceeds 1 000ml, and blood
pressure is usually maintained in the normal range. A blood
loss of up to 1 500ml will begin to manifest clinical signs, such
as a rise in pulse and respiratory rate, and a slight recordable
fall in systolic blood pressure. Systolic blood pressure below
80mmHg usually indicates a blood loss in excess of 1 500ml
clinically associated with worsening tachycardia, tachypnea,
and alteration of mental status.
Definitions based on symptoms of hemodynamic instabil-
ity are therefore problematic, as they are late signs of depleted
blood volume and commencing failure of compensatory
mechanisms. The relative masking of signs during pregnancy
hinders early recognition of hypovolemia and delays treat-
ment, resulting in further blood loss and increased risk of
hemorrhagic shock. Consequently, hypovolemic women who
begin to decompensate, as evidenced by hypotension, will de-
teriorate extremely rapidly (53). Furthermore, confounding
factors such as drug-induced tachycardia, e.g. by oxytocin
or nifedipine, or hypovolemia due to antenatal blood loss
should be taken into account.
Diagnosis of PPH
Proper and timely diagnosis of PPH may follow the principles
shown in Table 4. First, the early recognition of patients at
increased risk of PPH prior to delivery is useful, although the
assessment of risk factors is of limited predictive value. In ad-
Table 4. Diagnosis of postpartum hemorrhage (PPH) and adverse clinical
events.
Timely recognition of patients at increased risk of PPH prior to delivery
Proper estimation of blood loss before vital signs change
Accurate visual estimation (teaching tools clinical reconstructions
and pictorial algorithm (EL lb) (Bose et al. 2006, 53)
Objective measurement of blood loss (such as BRASSS-V blood
collection drape with calibrated receptacle): EL lb
Close monitoring of the patients condition
Use of Early Warning Scores (MEOWS): Mental response, pulse rate,
systolic blood pressure, respiratory rate: EL Illc
Laboratory tests, especially to recognize coagulopathy in time
Clinical diagnosis of PPH-cause at the earliest time to institute
adequate treatment (pharmacological and/or surgical treatment)
EL, level of evidence.

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Postpartum hemorrhage - definitions and diagnosis
dition, proper estimation of blood loss is needed before vital
signs change. There is consistent evidence that the accuracy
of visual estimation of blood loss can be improved signifi-
cantly by simulating clinical scenarios with known measured
blood loss or using pictorial algorithms as a teaching tool in
labor wards (53). Several recent studies have addressed this
issue (47,5355). Interestingly, among professional groups
the anesthetists were the most accurate estimators of blood
loss, followed by midwives (53). Regular fire drills should
be organized to train staff in the assessment of blood loss and
to test local systems in real time (14).
Recent studies have shown that low-cost calibrated plas-
tic bags, such as the BRASSS-Vdrape (excellentfixabled@
hotmail.com), are useful tools to measure blood loss at vagi-
nal delivery before the maternal cardiovascular system dete-
riorates (50). Drape estimation of blood loss was found to
be 33% more accurate than visual estimation, and use of the
drape resulted in a diagnosis of PPH four times as often as
the visual estimate (37). The drape-measured blood loss was
equally good and as efficient as gold-standard spectropho-
tometry. Use of the drape has been shown to lead to earlier
transfer from rural areas to a higher medical facility (50).
The effect of a collector bag for measurement of postpar-
tum blood loss after vaginal delivery was recently studied in
a cluster randomized trial in 13 European countries (56).
Maternity units were randomly assigned to systematic use of
a collector bag or to continue to visually assess postpartum
blood loss after vaginal delivery. The rate of severe PPH was
not significantly different between the groups (1.7 vs. 2.06%).
These findings questioned the benefit of collector bag use in
reducing the rate of severe PPH at vaginal delivery. How-
ever, further research is needed to test the collector bag in
connection with other effective management strategies.
Laboratory-based methods for measuring blood loss (such
as photometric techniques) are not practical for clinical use
but may be suitable in research (25).
If PPH is suspected, careful surveillance of the mother is
mandatory for a timely recognition of impending hemody-
namic instability and for early detection of concealed intra-
abdominal bleeding, especially after cesarean section.
Reflecting on the relation between clinical signs of hem-
orrhagic shock and volume of blood loss, as described by
Bonnar (52), a classification has been proposed for a more
practical approach using an alert- and an action-line (16). A
perceived loss of 5001 000ml in the absence of clinical signs
of shock and cardiovascular instability should prompt ba-
sic measures of monitoring and readiness for resuscitation
(alert line), and a perceived loss >1 000ml or a less associated
with clinical signs of shock should prompt a full protocol
of measures to resuscitate, monitor, and arrest the bleeding
(action-line). This classification is in accordance with the
recent Royal College of Obstetricians and Gynaecologists
guideline (30).
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Postpartum hemorrhage - definitions and diagnosis
An Early Warning Score modified slightly for obstetric use
(MEOWS) is a simple scoring system that can be performed
at the patients bedside using commonly available clinical
parameters for the sick (14). The principle is that smaller
changes in all the parameters combined will be noticed earlier
than a large change in one parameter alone. For example,
a marked drop in blood pressure is usually a late sign of
hypovolemia, whereas respiratory rate is one of the most
sensitive markers of well being.
This warning score system is suitable only for labor wards
with sufficient staff, and may be too complex to use in the
emergency of an acute PPH, and may also not be proposed
for full implementation in areas which are resource-poor.
Nevertheless, monitoring of the mothers vital signs is
imperative. Laboratory tests including coagulation testing
should be performed, in particular to diagnose life-
threatening coagulopathy at the earliest time. Finally, imme-
diate diagnosis of the cause of PPH is required for adequate
pharmacological and/or surgical treatment.
Conclusions
PPH is a significantly underestimated obstetric problem, pri-
marily because of a lack of definition and diagnosis. There is
an urgent need to unify commonly used definitions of PPH
and to create a definition that is appropriate for both high-
and low-income countries. A measured blood loss of 1 000ml
may be an appropriate cut-off to define PPH, irrespective of
the mode of delivery. For clinical purposes, an adequate defi-
nition of PPH should also consider early signs and symptoms
of hypovolemia, although it must be kept in mind that in-
creased circulating blood volume in pregnancy may mask
clinical symptoms of hypovolemic shock.
The accurate estimation of blood loss will allow correctly
timed and appropriate intervention by warning of impend-
ing hypovolemic shock. Visual estimation of blood loss is
of limited value, as underestimation is common, but can be
improved significantly by simulating clinical scenarios with
known measured blood loss or using pictorial algorithms as
a teaching tool in labor wards. Training should be provided
to all staff involved in maternity care concerning assessment
of blood loss and the monitoring of women after birth. The
use of calibrated collection bags has proven to be a useful
tool for a more accurate measurement of postpartum blood
at vaginal deliveries.
The most important key factors for a proper and timely
diagnosis of PPH are (57):
1. accurate estimation of blood loss before vital signs change;
2. careful monitoring of the mothers vital signs [note
the Modified Obstetric Early Warning Scoring (MOEWS)
system]);
3. coagulation testing, to diagnose impending coagulopathy
early; and
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W.H. Rath
4. immediate diagnosis of the cause to initiate appropriate
treatment.
This will counteract the development of severe PPH and
prevent adverse outcomes.
Funding
No specific funding.
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