Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study

ObjectiveTo quantify reporting errors, measure incidence of postpartum haemorrhage (PPH) and define risk factors for PPH (500ml) and progression to severe PPH (1500ml). DesignProspective observational study. SettingTwo UK maternity services. PopulationWomen giving birth between 1 August 2008 and 31 July 2009 (n=10213). MethodsWeighted sampling with sequential adjustment by multivariate analysis. Main outcome measuresIncidence and risk factors for PPH and progression to severe PPH. ResultsErrors in transcribing blood volume were frequent (14%) with evidence of threshold preference and avoidance. The incidences of PPH500, 1500 and 2500ml were 33.7% (95% CI 31.2-36.2), 3.9% (95% CI 3.3-4.6) and 0.8% (95% CI 0.6-1.0). New independent risk factors predicting PPH500ml included Black African ethnicity (adjusted odds ratio [aOR] 1.77, 95% CI 1.31-2.39) and assisted conception (aOR 2.93, 95% CI 1.30-6.59). Modelling demonstrated how prepregnancy- and pregnancy-acquired factors may be mediated through intrapartum events, including caesarean section, elective (aOR 24.4, 95% CI 5.53-108.00) or emergency (aOR 40.5, 95% CI 16.30-101.00), and retained placenta (aOR 21.3, 95% CI 8.31-54.7). New risk factors were identified for progression to severe PPH, including index of multiple deprivation (education, skills and training) (aOR 1.75, 95% CI 1.11-2.74), multiparity without caesarean section (aOR 1.65, 95% CI 1.20-2.28) and administration of steroids for fetal reasons (aOR 2.00, 95% CI 1.24-3.22). ConclusionsSequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date.