Postpartum hemorrhage is the highest cause of maternal deaths.

Although the
maternal mortality rate has dropped dramatically in developing countries,
postpartum hemorrhage remains a significant cause of maternal mortality most
everywhere.
Pregnancy-related maternal deaths are directly in the United States is estimated to
7-10 women per 100,000 live births. National statistics of the United States said
about 8% of these deaths are due to postpartum hemorrhage. In industrialized
countries, postpartum hemorrhage is usually found on the top ranked third cause
of maternal death, compete with embolism, and hypertension. In some developing
countries the maternal mortality rate exceeding 1000 women per 100,000 live
births, and the WHO data show that 25% of maternal deaths due to postpartum
hemorrhage and an estimated 100,000 deaths each year matenal.
Postpartum hemorrhage is defined as blood loss of 500 ml after vaginal delivery
or more than 1,000 ml after abdominal delivery. Bleeding in this amount in less
than 24 hours is referred to as primary postpartum hemorrhage, and if this
bleeding occurs more than 24 hours is referred to as secondary postpartum
hemorrhage.
The frequency of postpartum hemorrhage were reported Mochtar, R. et al. (1965-
1969) in R.S. Pirngadi Medan is 5.1% of all deliveries. From the reports both in
developed countries and in developing countries the incidence rate ranged from
5% to 15%. From these figures, obtained distribution of etiology, among others:
atonic (50-60%), retained placenta (23-24%), retained placenta (16-17%),
lacerations of the birth canal (4-5%), blood disorders ( 0.5 to 0.8%).
Handling of postpartum hemorrhage should be done in two components: (1)
resuscitation and treatment of obstetric hemorrhage and hypovolemic shock
possibilities and (2) the identification and treatment of the causes of postpartum
hemorrhage.
Definition

Postpartum hemorrhage (PPH) is commonly defined as blood loss exceeding 500

milliliters (mL) following vaginal birth and 1000 mL following
cesarean.1 Definitions vary, however, and diagnosis of PPH is subjective and often
based on inaccurate estimates of blood loss.1-4 Moreover, average blood loss at
birth frequently exceeds 500 or 1000 mL,4 and symptoms of hemorrhage or shock
from blood loss may be hidden by the normal plasma volume increases that occur
during pregnancy. Proposed alternate metrics for defining and diagnosing PPH
include change in hematocrit, need for transfusion, rapidity of blood loss, and
changes in vital signs, all of which are complicated by the urgent nature of the
condition.1 PPH is often classified as primary/immediate/early, occurring within
24 hours of birth, or secondary/delayed/late, occurring more than 24 hours post-
birth to up to 12 weeks postpartum. In addition, PPH may be described as third or
fourth stage depending on whether it occurs before or after delivery of the
placenta, respectively.

Prevalence

The overall prevalence of PPH worldwide is estimated to be 6 to 11 percent of

births with substantial variation across regions.5, 6 Prevalence differs by
assessment method and ranges from 10.6 percent when measured by objective
appraisal of blood loss to 7.2 percent when assessed with subjective techniques to
5.4 percent when assessment is unspecified.5 Multiple studies have noted an
increase in PPH in high-resource countries, including the United States, Canada,
Australia, Ireland, and Norway, since the 1990s.7-11 In the United States, one study
found that the incidence of PPH increased 26% from 1994 to 2006 (2.3% vs.
2.9%, respectively, p < 0.001).12 Another U.S. study reported the incidence of
severe PPH doubled from 1.9 percent in 1999 to 4.2 percent in 2008 (p <
0.0001).13 Factors underlying the increase remain unclear, and both recent U.S.
studies found rising PPH rates were not explained by changes in risk factors (e.g.,
maternal age, cesarean birth, multiple gestation).12, 13

etiology

The commonest causes of postpartum hemorrhage referred to as 4T:

4T Specific cause Frekuensi

Tone Atonia uteri 70%
Trauma Laserasion, hematom, inversi 20%
Tissue Retensio plasenta 10%
Thrombin coagulopati 1%

The main risk factors affecting postpartum haemorrhage by Sarwono is

like the age, gravida, parity, spacing between births, antenatal care, and
hemoglobin concentration.

Age safe for pregnancy and childbirth is 18-35 years, because at that
age the uterus is ready to face the pregnancy, mental ripe, and have been able to
care for the baby and herself. Maternal deaths in pregnancy and childbirth at the
age of less than 18 and more than 35 years, it was 2 to 5 times higher than
maternal deaths occur at ages 18-35. In women younger than 18 years old,
physically and mentally not ready again to face pregnancy and pesalinan. In
addition, the womb and the mother's pelvis is not fully developed, so needs to
diwaspada against interruption of pregnancy. In contrast to the mothers over the
age of 35 years, they are likely to experience birth complications.

Mothers with pregnancies of more than 1 time have a higher risk of

postpartum hemorrhage compared with mothers who belonged primigravidae.
This is because the reproductive function decreased in every delivery.
 Parity 2-3 is the most secure parity terms of the PPH that can lead to
maternal death. Parity is greater than or equal to 4 have a greater risk for
postpartum hemorrhage due in multiparas uterine muscles are often stretched to
the wall thins and the contractions become weaker.

In addition, the spacing is too close (<2 years) will lead to uterine
contractions become less good and progressive maternal health retreat. This
causes the incidence of postpartum hemorrhage more tinggi.Selama next
pregnancy takes 2-4 years for the condition of the mother's body back to their
previous condition.

Onwards, good antenatal checks and the availability of referral facilities

for high-risk cases, especially bleeding that may always occur after childbirth,
lead to maternal death can be reduced. This is because the presence of antenatal
care early signs of excessive bleeding can be detected and dealt with quickly.
Finally, anemia is a condition characterized by a decrease in hemoglobin values
below the normal value, if the hemoglobin level is less than 8gr%. Shortage of
hemoglobin in the blood can cause serious complications for both the mother
during pregnancy, childbirth, and postpartum which can result in one of them is
postpartum hemorrhage due to uterine atony.

Pathogenesis

The incidence of excessive blood loss following vaginal delivery is 5-8%.

Postpartum hemorrhage is the most common cause of excessive blood loss in
pregnancy and most transfusion in pregnant women are performed to replace
blood lost after delivery. Hemorrhage is the third leading cause of maternal
mortality in United States and is directly responsible for approximately one sixth
of maternal death. Ih less developed countries, hemorrhage is among the leading
obstetric cause of maternal death.
Cause of postpartum hemorrhage include uterine atony, obstetric laceration,
retained placental tissue and coagulation defects.

A. Uterine Atony
Postpartum bleeding is physiologically controlled by constriction of
interlacing myometrial fiber that surround the blood vessels supplying the
placental implantionsite. Uterine atony exist when the myometrium cannot
contract.
Atony is the most common cause of postpartum hemorrhage (50%).
Predisposing cause include axcessive manipulation of the uterus, general
anesthesia (particularly with halogenated compounds), uterine
overdistention (twins of polyhydramnions), prolonged labor, grand
multipaity, uterine laiomyomas, operative delivery and intrauterine
manipulation, oxytocin induction or augmentation of labor, previos
hemorrhage in third stage, uterine infection, extravasation of blood into the
myometrium (couvelaire uterus) and intrinsic myometrial dysfunction.

B. Obstetric Laserations
Excessive bleeding from an episiotomy, lacerations of both causes
approximately 20% of postpartum hemorrhage laceratios can ivolve the
uterus, cevix, vagina or vulva. Laceration of blood vessels underneath the
vaginal or vulva epithelium results in hematomas. Bleedingis concealed an
can be particularly dangerous because it may go unrecognized for several
hours and become apparent only when shock become apparent only when
shock occurs.