Risk factors for postpartum haemorrhage

Bibliographic reference Study type Evidence level Number of patients Patient characteristics Intervention Comparison Length of follow-up Outcome measures Effect size Source of funding Additional comments
Gilbert L;Porter W;Brown VA; 1987 Jan
571
Case-controlEvidence level: 2−N=437 (PPH=86 non-PPH=351)pregnant womenIntervention: parity, labour induction, mode of birth, duration of labour, oxytocinComparison: PPH or non-PPHFollow-up period: during pregnancyOutcome Measures: PPHParity p<0.001
Induction of labour p<0.001
Duration of first stage p<0.001
Duration of second stage p<0.001
Mode of birth p<0.001
not stated
Henry A;Birch M;Sullivan EA;Katz S;Wang YA;

2005

572
Case-controlEvidence level: 2+N=250(125 for each)pregnant womenIntervention: obstetric risk factorsComparison: PPH or non-PPHFollow-up period: during pregnancyOutcome Measures: PPHpast history of PPH
adjusted OR 14.11 [1.62 to 123.06]

prolonged second stage
longer than or equal to 60min, adjusted OR 2.68 [1.27 to 5.64]

forceps birth
adjusted OR 3.47 [1.35 to 8.91]

incomplete/ragged membranes adjusted OR 3.56 [1.52 to 8.36]
not stated
Bais JMJ;Eskes M;Pel M;Bonsel GJ;Bleker OP;

2004

573
Cross-sectionalEvidence level: 3N=3464pregnant women nulliparousIntervention: obstetric risk factorsComparison: developing PPH or notFollow-up period: N/AOutcome Measures: PPH (blood loss more than 500 or 1000mls)Risk factor for moderate PPH(500ml or more blood loss)
retained placenta
adjusted OR 7.83 [3.78 to 16.22]

prolonged third stage (longer than 30 min)
adjusted OR 2.61 [1.83 to 3.72]

multiple pregnancy
adjusted OR 2.60 [1.06 to 6.39]

episiotomy
adjusted OR 2.18 [1.68 to 2.81]

macrosomia (weight more than or equal to 4kg)
adjusted OR 2.11 [1.62 to 2.76]

perineal trauma (laceration severer than or equal to first degree)
adjusted OR 1.40 [1.04 to 1.87]

west European race
adjusted OR 1.32 [1.00 to 1.73]

Risk factors for severe PPH (1000ml or more blood loss)
retained placenta
adjusted OR 11.73 [5.67 to 24.1]

prolonged third stage (longer than or equal to 30 minutes)
adjusted OR 4.90 [2.89 to 8.32]

macrosomia
adjusted OR 2.55 [1.57 to 4.18]

perineal trauma (laceration severer than or equal to first degree)
adjusted OR 1.82 [1.01 to 3.28]

risk factors of severe PPH for low risk women
retained placenta
adjusted OR 21.6 [5.99 to 78.00]

prolonged third stage (longer than 30 min)
adjusted OR 3.59 [1.60 to 8.03]

Risk factors of severe PPH for high risk women
retained placenta
adjusted OR 9.29 [3.69 to 23.4]

prolonged third stage (longer than 30 min)
adjusted OR 6.11 [2.94 to 12.7]

macrosomia
adjusted OR 2.75 [1.52 to 4.97]

induction
adjusted OR 1.74 [1.06 to 2.87]

prolonged second stage (more than or equal to 30 min)
adjusted OR 2.74 [1.37 to 5.49]
not stated
Chichakli LO;Atrash HK;MacKay AP;Musani AS;Berg CJ;

1999

574
Cross-sectionalEvidence level: 3N=763pregnant womenIntervention: obstetric risk factorsComparison: developing PPH or notFollow-up period: N/AOutcome Measures: mortality due to PPHAge
<20 RR 1.00 [0.7 to 1.4]
20–24 RR 1
25–29 RR 1.6 [1.2 to 1.9]
30–34 RR 2.8 [2.3 to 3.6]
35–39 RR 5.2 [4.0 to 6.6]
40–49 RR 12.9 [9.2 to 17.9]

Mortality Ratio by race
White; black; other
<20=0.5;1.4; 0.5
20–24=0.5;1.7;0.8
25–29=0.9;2.6;2.1
30–34=1.4; 7.0; 4.6
35–39=2.9; 10.4; 6.2
40–49=6.8; 24.5; 16.3
not stated
Hall MH;Halliwell R;Carr-Hill R;
1985 Jul
575
Cross-sectionalEvidence level: 3N=36312pregnant womenIntervention: obstetric risk factorsComparison: developing PPH or notFollow-up period: N/AOutcome Measures: PPHincidence of PPH
induced; not induced; total
Primiparae=5.9%;3.5%;4.5%
Multiparae=4.5%;2.8%; 3.4%
Total=5.2%; 3.1%; 3.9%
Not stated
Magann EF;Evans S;Hutchinson M;Collins R;Howard BC;Morrison JC;

2005

576
Cross-sectionalEvidence level: 3N=13868pregnant womenIntervention: obstetric risk factorsComparison: developing PPH or notFollow-up period: N/AOutcome Measures: PPHRisk factors of developing PPH (blood loss 1000ml or greater and/or need for a transfusion)

Asian race
adjusted OR 1.8 [1.4 to 2.2]

maternal blood disorders
adjusted OR 1.3 [1.1 to 1.6]

prior PPH
adjusted OR 1.8 [1.4 to 2.2]

history of retained placenta
adjusted OR 6.2 [4.6 to 8.2]

multiple pregnancy
adjusted OR 2.2 [1.5 to 3.2]

antepartum haemorrhage
adjusted OR 1.8 [1.3 to 2.3]

genital tract lacerations
adjusted OR 1.7 [1.4 to 2.1]

macrosomia (4kg or greater)
adjusted OR 1.8 [1.4 to 2.3]

induction of labour
adjusted OR 1.8 [1.4 to 2.2]

chorioamnionitis
adjusted OR 1.3 [1.1 to 1.7]

intrapartum haemorrhage
adjusted OR 1.5 [1.0 to 2.3]

intrauterine fetal deaths
adjusted OR 2.6 [1.1 to 5.7]

compound fetal presentation
adjusted OR 3.0 [1.1 to 7.3]

epidural anaesthesia
adjusted OR 1.3 [1.0 to 1.6]

prolonged first/second stage of labour
first stage
adjusted OR 1.6 [1.0 to 1.6]
second stage
adjusted OR 1.6 [1.1 to 2.1]

forceps birth after failed vacuum
adjusted OR 1.9 [1.1 to 3.2]
Not stated
Stones RW;Paterson CM;Saunders NJ;

1993

577
Cross-sectionalEvidence level: 3N=37497pregnant womenIntervention: obstetric risk factorsComparison: developing PPH or notFollow-up period: N/AOutcome Measures: PPHMultiple pregnancies
RR 4.46 [3.01 to 6.61]

Maternal age <20 years
RR 0.81 [0.45 to 1.43]

maternal age >35 years
RR 1.42 [1.00 to 2.02]

BMI >27
RR 1.64 [1.24 to 2.17]

Para >4
RR 1.09 [0.56 to 2.14]

Smoking
RR 0.89 [0.66 to 1.21]

Antenatal anaemia
RR 1.24 [0.82 to 1.89]

Essential hypertension
RR 1.43 [0.65 to 3.14]

Non-proteinuric PIH
RR 1.7 [1.16 to 2.50]

Proteinuric PIH
RR 1.15 [0.32 to 4.19]

Indeterminate antepartum haemorrhage
RR 1.67 [0.82 to 3.44]

Proven abruption
RR 12.6 [7.61 to 20.9]

Praevia with bleeding
RR 13.1 [7.47 to 23.0]

Praevia without bleeding
RR 11.3 [3.36 to 38.1]
not stated
Dewar MJ;

1969 Feb

578
CohortEvidence level: 2−N=171pregnant womenIntervention: AnaemiaComparison: postpartum haemorrhageFollow-up period: intrapartumOutcome Measures: Postpartum haemorrhagewomen with antenatal Hgb<10.5g/dl and Hct <35 11.1%

Women with antenatal Hgb<10.5g/dl or Hct <35 2.1%

Women with antenatal Hgb 10.5 or greater and/or
Hct 35%
13.3%
not stated
Ogueh O;Morin L;Usher RH;Benjamin A;
2003 Oct 579
Cross-sectionalEvidence level: 3N=7641 (703 with low-lying placenta and 6938 normal women)pregnant womenIntervention: low-lying placentaComparison: normal lying placentaFollow-up period: intrapartumOutcome Measures: PPH
(blood loss 500 ml or greater for vaginal birth, 1000ml or greater for casarean section)
adjusted OR 1.72 [1.12 to 2.66], adjusted for maternal age and birth weightnot stated
Guirgis RR;Clark AD;Hogston P;Golland IM;Bevan JR;Francis JG;Higgins B;
1997580
CohortEvidence level: 2-N=800(400 non-smoking and 400 smoking)pregnant womenIntervention: smokingComparison: non smokingFollow-up period: intrapartumOutcome Measures: postpartum haemorrhageRR 1.57, p=0.03Not stated
Cheng YW;Hopkins LM;Caughey AB;
2004326
Cross-sectionalEvidence level: 3N=15759pregnant womenIntervention: prolonged second stageComparison: normal duration of second stageFollow-up period: N/AOutcome Measures: postpartum haemorrhageRR 1.05 [0.84 to 1.31]Not stated
Janni W;Schiessl B;Peschers U;Huber S;Strobl B;Hantschmann P;Uhlmann N;Dimpfl T;Rammel G;Kainer F;
2002 328
Cross-sectionalEvidence level: 3N=1200pregnant womenIntervention: prolonged second stage labour (2hours)Comparison: normal duration of second stage labourFollow-up period: intrapartumOutcome Measures: PPHRR 2.3 [1.6 to 331]not stated
Saunders NS;Paterson CM;Wadsworth J;
1992 May 332
Cross-sectionalEvidence level: 3N=25069pregnant womenIntervention: prolonged second stageComparison: normal duration of second stageFollow-up period: intrapartumOutcome Measures: PPH (blood loss more than 500mls)duration of second stage
<120=RR 1
120–179=RR 1.6 [1.3 to 1.9]
180–239=RR 1.7 [1.3 to 2.3]
240-=RR 1.9 [1.2 to 2.8]
not stated
Cohen WR;
1977 Mar 335
Cross-sectionalEvidence level: 3N=4403pregnant womenIntervention: duration of second stageComparison: duration of second stageFollow-up period: intrapartumOutcome Measures: postpartum haemorrhageduration of second stage and puerperal haemorrhage p<0.001not stated
Myles TD;Santolaya J; 327Cross-sectionalEvidence level: 3N=7818pregnant womenIntervention: prolonged second stage (>120min)Comparison: normal duration of second stageFollow-up period: intrpartumOutcome Measures: psotpartum haemorrhageRR 2.70, p<0.001not stated
Sebire NJ;Jolly M;Harris JP;Wadsworth J;Joffe M;Beard RW;Regan L;Robinson S;
2001581
Cross-sectionalEvidence level: 3N=325395pregnant womenIntervention: increased body mass index (25 or greater)Comparison: normal body mass indexFollow-up period: postnatalOutcome Measures: PPH (blood loss greater than 1000ml)BMI 25–30
adjusted OR 1.16 [99%CI 1.12 to 1.21]

BMI >30
adjusted OR 1.39 [99%CI 1.32 to 1.46]

controlling for other factors including ethnicity, parity, age and history of hypertension
not stated
Usha Kiran TS;Hemmadi S;Bethel J;Evans J;
2005582
Cross-sectionalEvidence level: 3N=60167pregnant womenIntervention: increased body mass index (greater than 30)Comparison: normal body mass indexFollow-up period: intrapartumOutcome Measures: PPH (blood loss greater than 500ml)OR 1.5 [1.2 to 1.8]not stated
Robinson HE;O’Connell CM;Joseph KS;McLeod NL;
2005583
Cross-sectionalEvidence level: 3N=142404pregnant womenIntervention: over weight (over 90kg)Comparison: normal weightFollow-up period: postnatalOutcome Measures: developing PPHmoderately overweight women (90 – 120kg)
adjusted OR 1.12 [1.02 to 1.22]

severely overweight women (heavier than 120kg)
adjusted OR 1.07 [0.80 to 1.42]
not stated
Sebire NJ;Jolly M;Harris J;Regan L;Robinson S;
2001 Jan 584
Cross-sectionalEvidence level: 3N=215105pregnant womenIntervention: low body mass index (20–25)Comparison: normal body mass indexFollow-up period: postnatalOutcome Measures: PPHPPH
adjusted OR 0.85 [99%CI 0.80 to 0.90]

severe PPH
adjusted OR 0.83 [99%CI 0.72 to 0.95]
not stated
Olesen AW;Westergaard JG;Olsen J;
2003 Jul585
Cross-sectionalEvidence level: 3N=47021pregnant womenIntervention: postterm pregnancyComparison: termFollow-up period: postnatalOutcome Measures: PPHadjusted OR 1.37 [1.28 to 1.46]not stated
Jolly MC;Sebire NJ;Harris JP;Regan L;Robinson S;
2003586
Cross-sectionalEvidence level: 3N=350,311pregnant womenIntervention: macrosomia (birth weight more than 4kg and birth weight heavier than 90th centile)Comparison: normal birth weightFollow-up period: N/AOutcome Measures: developing PPHbabies whose birth weight were more than 4kg
adjusted OR 2.01 [99%CI 1.93 to 2.10]

babies whose birth weight more than 90th centile
adjusted OR 1.63 [99%CI 1.56 to 1.71]
not stated
McEwan HP;Murdoch R;
1966 Oct 587
Cross-sectionalEvidence level: 3N=7,992pregnant womenIntervention: macrosomiaComparison: normal size babiesFollow-up period: N/AOutcome Measures: developing PPHRR=1.81 no p-valuenot stated
Stotland NE;Caughey AB;Breed EM;Escobar GJ;
2004 Dec 588
Cross-sectionalEvidence level: 3N=146,526pregnant womenIntervention: macrosomiaComparison: normal birth weightFollow-up period: N/AOutcome Measures: developing PPH4000–4499g birth weight
adjusted OR 1.69 [1.58 to 2.10]

4500–4999g birth weight
adjusted OR 2.15 [1.86 to 2.48]

5000g or greater birth weight
adjusted OR 2.03 [1.33 to 3.09]
not stated
Wollschlaeger K;Nieder J;Koppe I;Hartlein K;
1999589
Cross-sectionalEvidence level: 3N=7363 (birth weight 4kg or greater=956; birth weight 3–3.9kg=6407)pregnant womenIntervention: macrosomia(4kg or greater)Comparison: normal birth weight(3–3.9kg)Follow-up period: N/AOutcome Measures: developing PPHRR 1.77, p<0.001not stated
Jolly M;Sebire N;Harris J;Robinson S;Regan L;

2000590
Cross-sectionalEvidence level: 3N=385,120pregnant womenIntervention: age 35 years or greaterComparison: age less than 35 yearsFollow-up period: N/AOutcome Measures: developing PPHage 35–40 and moderate PPH
adjusted OR 1.14 [99%CI 1.09 to 1.19]

age greater than 40 and moderate PPH
adjusted OR 1.27 [99%CI 1.15 to 1.39]

age 35–40 and severe PPH
adjusted OR 1.28 [99%CI 1.16 to 1.41]

age greater than 40 and severe PPH
adjusted OR 1.55 [99%CI 1.29 to 1.88]
not stated
Ohkuchi A;Onagawa T;Usui R;Koike T;Hiratsuka M;Izumi A;Ohkusa T;Matsubara S;Sato I;Suzuki M;Minakami H;
2003591
Cross-sectionalEvidence level: 3N=10,053pregnant womenIntervention: age 35 years or olderComparison: age younger than 35 yearsFollow-up period: N/AOutcome Measures: developing PPHWhen vaginal birth
adjusted OR 1.5 [1.2 to 1.9]

When CS
adjusted OR 1.8 [1.2 to 2.7]
not stated
Babinszki A;Kerenyi T;Torok O;Grazi V;Lapinski RH;Berkowitz RL;
1999 Sep 592
Cross-sectionalEvidence level: 3N=2642(133 great-grand multiparas, 314 grand multiparas and 2195 multiparas)pregnant womenIntervention: parityComparison: parityFollow-up period: N/AOutcome Measures: developing PPHmultiparous=0.3%
grand-multiparous=1.9%
p=0.001
not stated
Bugg GJ;Atwal GS;Maresh M;
2002593
Cross-sectionalEvidence level: 3N=794 (397 for each)pregnant womenIntervention: grand-multiparousComparison: multiparousFollow-up period: N/AOutcome Measures: developing PPHOR 1.18 [0.6 to 2.4]not stated
Chang A;Larkin P;Esler EJ;Condie R;Morrison J;
1977 Mar 5594
Cross-sectionalEvidence level: 3N=2634(low parity=2543; high parity=91)pregnant womenIntervention: high parity (more than 4)Comparison: low parityFollow-up period: N/AOutcome Measures: developing PPH (>600ml)low=5.0%
high=7.5%
p=0.76
not stated
Henson GL;Knott PD;Colley NV;
1987595
Cross-sectionalEvidence level: 3N=11420(grand-multiparous=216)pregnant womenIntervention: grand-multiparous (5 or more)Comparison: multiparousFollow-up period: N/AOutcome Measures: developing PPHhigher incidence for grand multiparous p<0.01not stated
Humphrey MD;
2003596
Cross-sectionalEvidence level: 3N=15,908 (653 grand multiparous women, compared with 15255 women with lower parity)pregnant womenIntervention: grand multiparousComparison: multiparousFollow-up period: N/AOutcome Measures: developing PPHOR 1.36 [0.99 to 1.87]not stated
Irvine LM;Otigbah C;Crawford A;Setchell ME;
1996597
Cross-sectionalEvidence level: 3N=458 (229 grand multiparity with controls matched for age with one parity)pregnant womenIntervention: grand multiparityComparison: multiparityFollow-up period: N/AOutcome Measures: developing PPHestimated blood loss
grand=310+/−255ml
control=263+/−306ml
p>0.01

PPH
grand=15%
control=15%
not stated
Toohey JS;Keegan Jr KA;Morgan MA;Francis J;Task S;DeVeciana M;
1995598
Cross-sectionalEvidence level: 3N=764(382 grand multiparous women, compared with aged matched controls with 2–4 parity)pregnant womenIntervention: grand-multiparityComparison: 2–4 parityFollow-up period: N/AOutcome Measures: developing PPHOR 0.97 [0.57 to 1.63]not stated
Yasmeen S;Danielsen B;Moshesh M;Gilbert WM;
2005599
Cross-sectionalEvidence level: 3N=290,572 (grand multipara=25,512; multipara=260, 060)pregnant women aged 30years or olderIntervention: parityComparison: parityFollow-up period: N/AOutcome Measures: developing PPHgrand multiparity, compared with multiparity adjusted OR 1.2 [1.1 to 1.3]not stated

From: Evidence tables

Cover of Intrapartum Care
Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth.
NICE Clinical Guidelines, No. 55.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2007 Sep.
Copyright © 2007, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.