European Journal of Cardiovascular Medicine

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide. It accounts for nearly 25–30% of all maternal deaths globally, with the highest burden in low- and middle-income countries (LMICs) [1]. According to the World Health Organization (WHO), approximately 14 million women experience PPH each year, contributing significantly to preventable maternal deaths despite the availability of effective interventions [2]. In India, PPH continues to be a major public health challenge and is responsible for 20–25% of maternal deaths, making it a key target for national maternal health programs [3].

PPH is traditionally defined as blood loss of ≥500 mL following vaginal delivery or ≥1000 mL after cesarean section, or any blood loss resulting in hemodynamic instability irrespective of volume [4]. Primary PPH, occurring within 24 hours of birth, is far more common and severe than secondary PPH. The etiology of PPH is frequently summarized by the “Four Ts”—Tone (uterine atony), Tissue (retained placenta), Trauma (genital tract injury), and Thrombin (coagulation disorders)—with uterine atony responsible for nearly 70–80% of cases [5].

Multiple maternal, obstetric, and fetal risk factors influence the occurrence of PPH. These include anemia, prolonged labor, multiple pregnancy, induction or augmentation of labor, preeclampsia, operative deliveries, and placental abnormalities [6]. Identifying these risk factors is crucial for timely preparedness, risk stratification, and early intervention. However, the distribution and strength of these determinants may vary across regions and health-care settings, particularly in resource-limited tertiary hospitals where patient loads are high and delays in referral are common.

Despite significant improvements in institutional deliveries and emergency obstetric care under national programs, gaps persist in early identification and management of women at risk of PPH in India. Understanding the clinical profile, determinants, and immediate outcomes of PPPH in specific hospital settings is essential to guide targeted interventions, optimize labor room readiness, and reduce maternal morbidity and mortality.

This cross-sectional study aims to evaluate the clinical characteristics and major determinants of postpartum hemorrhage among women delivering at a tertiary care hospital, thereby contributing to evidence-based improvements in obstetric care and maternal health outcomes.

This cross-sectional study was conducted in the Department of Obstetrics and Gynaecology at a tertiary health-care institute during the period of January 2024 to December 2024. A total of 53 women diagnosed with postpartum hemorrhage (PPH) during the study period were included. PPH was defined as blood loss ≥500 mL following vaginal delivery or ≥1000 mL after cesarean section, or any amount of blood loss causing hemodynamic instability. All cases fulfilling the diagnostic criteria for primary PPH within 24 hours of delivery were eligible. Women with secondary PPH, incomplete records, or referred after initial management elsewhere were excluded. Data were obtained from labor room registers, case sheets, operative notes, and hospital information system records using a structured proforma. Variables collected included socio-demographic details, obstetric history, antenatal risk factors, type of delivery, clinical presentation at onset of PPH, estimated blood loss, cause of PPH, and immediate maternal outcomes.

Data collection was performed by trained medical personnel to ensure uniformity and accuracy. Causes of PPH were categorized as uterine atony, retained placental tissue, genital tract trauma, or coagulation abnormalities. Details of management such as use of uterotonics, tranexamic acid, blood transfusion, balloon tamponade, compression sutures, and surgical interventions were recorded. Maternal outcomes assessed included hemodynamic instability, ICU admission, surgical morbidity, and mortality. Data were entered into Microsoft Excel and analyzed using descriptive statistics such as frequency, percentage, mean, and standard deviation. Associations between determinants and PPH characteristics were explored using chi-square or Fisher’s exact test as applicable, with a p-value <0.05 considered statistically significant.

TABLE 1: Socio-Demographic Profile of Study Participants (n = 53)

Table 1 presents the socio-demographic characteristics of the 53 women included in the study. The majority of the participants were between 25–29 years of age (37.7%), followed by 20–24 years (34.0%), while 11.3% were adolescents (<20 years) and 17% were aged ≥30 years. Most women belonged to rural areas (60.4%), reflecting the catchment population of the tertiary health-care institute, whereas 39.6% were from urban locations. Educational status showed that 41.5% had completed secondary education, 26.4% had higher secondary or above, while 13.2% were illiterate. Regarding parity, more than half of the women were multiparous (54.7%), followed by primiparous (32.1%), and 13.2% were grand multipara, indicating that postpartum hemorrhage occurred across all parity groups, with higher representation among multiparous women.

TABLE 2: Obstetric and Antepartum Risk Factors Associated With PPH (n = 53)

Table 2 summarizes the obstetric and antepartum risk factors associated with postpartum hemorrhage among the study participants. Anemia was the most prevalent risk factor, observed in 64.2% of women, highlighting its significant contribution to PPH vulnerability. Hypertensive disorders such as PIH, preeclampsia, or eclampsia were present in 20.8% of cases.

Fig 1- Risk factors associated with PPH

A history of previous LSCS was noted in 26.4% of women, indicating the relevance of scarred uterus as a potential determinant. Induction or augmentation of labour was performed in 39.6% of deliveries, while prolonged labour was documented in 28.3% of cases. Less frequent but notable risk factors included multiple pregnancy (5.7%), polyhydramnios (7.5%), and placenta previa or abruption (11.3%). These findings reflect the multifactorial nature of PPH, with anemia, labour interventions, and obstetric complications contributing significantly to its occurrence.

TABLE 3: Clinical Characteristics and Causes of PPH (n = 53)

Table 3 describes the clinical characteristics and underlying causes of postpartum hemorrhage among the study participants. Most women delivered vaginally (60.4%), while 34% underwent cesarean section and 5.7% had instrumental deliveries. The estimated blood loss ranged from 500–1000 mL in 41.5% of cases, 1001–1500 mL in 34%, and exceeded 1500 mL in 24.5% of women, indicating that nearly one-fourth experienced severe hemorrhage. Analysis of the etiological factors based on the "4 Ts" revealed that uterine atony was the predominant cause, accounting for 71.7% of cases, followed by genital tract trauma in 13.2%, retained placental tissue in 9.4%, and coagulation abnormalities in 5.7%. These findings reinforce that uterine atony remains the major contributor to PPH, while trauma, tissue retention, and thrombin disorders occur less frequently but remain important clinical considerations.

TABLE 4: Management Interventions Used in PPH (n = 53)

Table 4 outlines the various management interventions utilized for postpartum hemorrhage in the study population. All women received oxytocin and intravenous fluids as first-line measures, reflecting standard protocol-based management. Misoprostol was administered in 90.6% of cases, while tranexamic acid was used in 84.9%, indicating their widespread adoption as adjunct therapies. Among second-line uterotonics, carboprost was used in 30.2% and ergometrine in 22.6% of women. More intensive interventions included blood transfusion in 54.7% of cases, highlighting the significant severity of blood loss in over half of the participants. Balloon tamponade was implemented in 17% of women, while uterine compression sutures such as B-Lynch were required in 11.3%. Uterine artery ligation was performed in 7.5% of cases, and emergency hysterectomy was necessary in 3.8%, reflecting the need for escalation of care in refractory PPH despite medical and conservative surgical measures.

TABLE 5: Maternal Outcomes Following PPH (n = 53)

Table 5 presents the maternal outcomes observed among women with postpartum hemorrhage. Hemodynamic instability occurred in 35.8% of cases, indicating significant acute circulatory compromise in more than one-third of the participants. Over half of the women (54.7%) required blood transfusion, highlighting the substantial severity of hemorrhage in the study population. ICU admission was necessary for 15.1% of women, reflecting the need for higher-level monitoring and critical care support.

Fig 2- Maternal Outcomes.

Surgical morbidity, including complications such as re-laparotomy or postoperative infections, was documented in 11.3% of cases. Additionally, 26.4% of women required hospitalization for more than three days, demonstrating prolonged recovery and increased healthcare resource utilization. One maternal death (1.9%) was recorded, underscoring that despite active management, PPH continues to pose a serious threat to maternal survival.

TABLE 6: Association Between Obstetric Risk Factors and Severity of PPH (n = 53)

A statistically significant association was observed between anemia and severe PPH (p = 0.002), indicating that women with low hemoglobin were more likely to have blood loss ≥1000 mL. Prolonged labour (p = 0.04) and induction/augmentation of labour (p = 0.03) also showed a significant association with PPH severity. However, other factors such as PIH, previous LSCS, and placental abnormalities did not demonstrate a statistically significant relationship with severe blood loss.

In the present cross-sectional study conducted at a tertiary health-care institute, we evaluated the clinical profile, determinants, management practices, and maternal outcomes of postpartum hemorrhage (PPH) among 53 women during 2024. The socio-demographic distribution in our study showed that most women belonged to the 20–29-year age group, which aligns with the reproductive age profile reported in similar Indian studies [7]. The predominance of rural participants corresponds with the typical referral patterns observed in tertiary centers located in semi-urban regions. Multiparity was more common among PPH cases, consistent with reports suggesting that repeated pregnancies predispose women to uterine atony and complications of labour [8].

Anemia emerged as the most frequent risk factor (64.2%) and showed a strong association with severe PPH. This is comparable to findings from the WHO Multicountry Survey, which emphasized anemia as a significant contributor to poor maternal outcomes in obstetric emergencies [9]. Labour-related factors—particularly induction/augmentation and prolonged labour—were also significantly associated with higher blood loss. Such associations have been consistently highlighted in literature, as uterine muscle fatigue following prolonged or stimulated labour can predispose to atony and subsequent hemorrhage [10]. Although hypertensive disorders and previous LSCS were present among the study population, their association with PPH severity was not statistically significant, similar to observations reported by other tertiary-care studies in India [11].

Uterine atony was the leading cause of PPPH in our study, accounting for 71.7% of cases. This aligns with global data showing atony as the cause in nearly 70–80% of PPH events [12]. Retained placental tissue and genital tract trauma were less frequent causes, reflecting a pattern consistent with previously published hospital-based analyses [13]. Prompt medical management with uterotonics was universal in our setting, with oxytocin and misoprostol used in the majority of cases. High utilization of tranexamic acid (84.9%) is noteworthy and reflects adherence to updated WHO recommendations, which advocate early use of antifibrinolytics in PPH management [14].

More advanced interventions—including balloon tamponade, compression sutures, and hysterectomy—were required in cases refractory to medical management. The hysterectomy rate (3.8%) is slightly lower compared with some Indian studies, possibly due to early recognition and timely application of conservative interventions at our center. More than half of the women required blood transfusion, signifying the clinical severity of hemorrhage and highlighting the need for maintaining adequate blood bank preparedness in obstetric units [15-20]. ICU admission was required in 15.1% of cases, and one maternal death (1.9%) occurred despite active interventions. Although mortality was low, it underscores that PPH persists as a major obstetric emergency with potential for rapid deterioration.

Overall, our findings reaffirm that PPH is a multifactorial condition strongly influenced by correctable determinants such as anemia, labour management practices, and timely intervention. Strengthening antenatal care, promoting early correction of anemia, optimizing labour supervision, and ensuring strict adherence to standardized PPH management protocols could significantly reduce morbidity and mortality. Future large-scale analytical studies are recommended to further explore risk factor interactions and to evaluate the effectiveness of PPH care bundles in improving outcomes in similar settings.

This cross-sectional study highlights that postpartum hemorrhage remains a major obstetric emergency with significant maternal morbidity and mortality, even in tertiary care settings. Uterine atony was identified as the leading cause of PPH, while anemia, prolonged labour, and induction or augmentation of labour were the key determinants associated with increased severity of blood loss. Early recognition, prompt medical management with uterotonics and tranexamic acid, and timely escalation to conservative or surgical interventions played a critical role in improving clinical outcomes. Despite comprehensive management, the need for ICU care and the occurrence of maternal mortality underscore the seriousness of the condition. Strengthening antenatal care with a focus on anemia correction, optimizing intrapartum monitoring, and ensuring readiness of PPH management protocols and blood bank services are crucial strategies to reduce the burden of PPH. Continued emphasis on evidence-based practices and institutional preparedness can substantially improve maternal safety and outcomes.

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