OBSTETRICS

OBSTETRICS

Blood Transfusion for Primary Postpartum

Hemorrhage: A Tertiary Care Hospital Review
Mrinalini Balki, MBBS, MD,1 Sudhir Dhumne, MBBS, MD,1 Shilpa Kasodekar, MBBS, MD,1
Gareth Seaward, MBBCh, FRCSC, MSc, Jose C.A. Carvalho, MD, PhD, FANZCA, FRCPC1,2
1

Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto ON

Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON

Abstract
Objective: To describe the common characteristics, clinical
management, and outcome of patients requiring blood transfusion
within 24 hours of delivery.
Methods: We conducted a retrospective cohort study of patients who
received blood transfusion for postpartum hemorrhage (PPH) in
the first 24 hours post-delivery, over a five-year period
(20002005). The medical records of patients were reviewed to
obtain information about demographics, pregnancy and delivery
characteristics, transfusion data, and complications.
Results: The overall blood transfusion rate for PPH was 0.31%
(104/33 631 deliveries). The rate of blood transfusion in women
who had a Caesarean section during labour was 0.49%, whereas
in women who had a vaginal delivery or elective Caesarean
section it was 0.28% and 0.23%, respectively. Antenatal risk
factors for PPH were identified in 61% of patients, and 39% of
patients developed intrapartum risk factors. The most important
etiological factors were uterine atony (38.5%) and retained
products of conception (33.7%). Twenty-one percent of the
patients developed coagulopathy, and 24% required admission to
the intensive care unit.
Conclusion: Severe primary PPH requiring blood transfusion can be
predicted in the majority of patients on the basis of antenatal risk
factors, while the remaining patients require vigilant monitoring for
risk factors during labour and delivery. In the multidisciplinary
effort to prevent and control major PPH, we should re-evaluate the
pharmacotherapy for PPH and ensure careful removal of retained
placental tissue after delivery.

Rsum
Objectif : Dcrire les caractristiques, la prise en charge clinique et
les issues courantes en ce qui concerne les patientes ncessitant
une transfusion sanguine dans les 24 heures suivant
laccouchement.
Mthodes : Nous avons men, sur une priode de cinq ans
(20002005), une tude de cohorte rtrospective portant sur des
patientes qui avaient reu une transfusion sanguine motive par
une hmorragie postpartum (HPP) au cours des 24 premires
heures suivant laccouchement. Les dossiers mdicaux des
Key Words: Postpartum hemorrhage, blood transfusion, risk
factors, vaginal delivery, Caesarean section
Competing Interests: None declared.
Received on January 28, 2008
Accepted on April 3, 2008

1002 l NOVEMBER JOGC NOVEMBRE 2008

patientes ont t analyss afin den tirer des renseignements

quant aux caractristiques dmographiques, aux caractristiques
de la grossesse et de laccouchement, aux donnes sur la
transfusion et aux complications.
Rsultats : Le taux global de transfusion sanguine motive par
lHPP tait de 0,31 % (104/33 631 accouchements). Le taux de
transfusion sanguine chez les femmes qui avaient subi une
csarienne au cours du travail tait de 0,49 %, tandis que chez les
femmes qui avaient connu un accouchement vaginal ou une
csarienne de convenance, il tait de 0,28 % et de 0,23 %,
respectivement. Des facteurs de risque prnatals en ce qui
concerne lHPP ont t identifis chez 61 % des patientes; 39 %
des patientes en sont venues prsenter des facteurs de risque
intrapartum. Les facteurs tiologiques les plus importants taient
latonie utrine (38,5 %) et la rtention de produits de conception
(33,7 %). Vingt et un pour cent des patientes en sont venues
prsenter une coagulopathie; 24 % des patientes ont ncessit
une admission lunit des soins intensifs.
Conclusion : Chez la plupart des patientes, lHPP primaire grave
ncessitant une transfusion sanguine peut tre prdite en fonction
de leurs facteurs de risque prnatals, tandis que chez les autres
patientes, une surveillance vigilante des facteurs de risque au
cours du travail et de laccouchement savre ncessaire. Dans le
cadre des efforts multidisciplinaires pour la prvention et la
matrise de lHPP majeure, nous devrions rvaluer la
pharmacothrapie visant lHPP et nous assurer du retrait intgral
des tissus placentaires la suite de laccouchement.
J Obstet Gynaecol Can 2008;30(11):10021007

INTRODUCTION

rimary postpartum hemorrhage is a major cause of

maternal morbidity and mortality worldwide, and certainly remains an important cause of near miss severe
morbidity in Canada.1,2 This major public health issue has
been further aggravated by a recent unexplained increase in
the frequency and severity of PPH in Canada.2 It has therefore been suggested that a review of severe maternal morbidity, which most commonly results from major PPH
requiring blood transfusion, may provide a better appraisal
of the threats to maternal health in pregnancy.

The interdisciplinary management of PPH involves resuscitation using fluid replacement, administration of uterotonic

Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review

drugs, a variety of surgical techniques to control bleeding,

and, if blood loss becomes excessive, blood transfusion.
The recent introduction of interventional radiologic techniques for selective uterine artery embolization has been
revolutionary in reducing blood loss during delivery in
women with a prior diagnosis of abnormal placentation3;
however, most PPH is due to uterine atony, and therefore is
not directly amenable to control using embolization methods. Being prepared for blood transfusion remains a very
important aspect of the management in women with this
severe complication.
Many studies have analyzed the risk factors associated with
PPH in women undergoing vaginal delivery and Caesarean
section, but no study has examined the subset of patients
requiring blood transfusion.46 The present study was
designed to identify the population at risk of major PPH
requiring blood transfusion at our institution, and to evaluate the clinical management and outcome of these patients.
METHODS

We conducted a retrospective cohort study of all obstetric

patients who reached at least 24 weeks of gestation and
received blood transfusion within 24 hours of delivery,
between June 1, 2000 and June 30, 2005. This period was
chosen because interventional radiologic techniques, which
complement the practice of modern obstetrics, were introduced into clinical practice during this time. The patients
with postpartum blood transfusion were identified through
a computerized search of the hospital database, and their
medical records were verified against the eligibility criteria.
Their charts were reviewed to assess (1) the risk factors for
PPH, (2) the pharmacological, surgical and interventional
radiology management undertaken, (3) the transfusion data,
and (4) the patient outcome.
PPH was identified if there was a blood loss in excess of
500 mL after a vaginal delivery, 1000 mL after CS, or a 10%
change in hematocrit. Other factors identifying PPH
included the need for blood transfusion, or any amount of
blood loss that threatened the womans hemodynamic stability.7 The risk factors for PPH, as described in previous
studies, included the factors that could be identified
antenatally and those presenting intrapartum.46
Antepartum factors included multiple gestation, abnormal
placentation, bleeding or coagulation disorders,
macrosomia, pregnancy-induced hypertension, chorioABBREVIATIONS
CS

Caesarean section

PPH

postpartum hemorrhage

PRBC

packed red blood cell

amnionitis, previous uterine surgery, or a history of PPH.

Intrapartum factors consisted of a prolonged first stage
of labour (latent labour > 20 hours in nullipara or
> 1 4 hours in multipara; cervical dilatation of
< 1 . 2 cm/hour in nullipara or < 1.5 cm/hour in
multipara), a prolonged second stage of labour (> 2 hours in
nullipara without epidural anaesthesia or > 3 hours in
nullipara with epidural anaesthesia; > 1 hour in multipara
without epidural anaesthesia or > 2 hours in multipara with
epidural anaesthesia), or a prolonged third stage of labour
( 30 minutes). Additional risk factors included labours that
were induced or augmented with oxytocin.4,5
At our institution, the pharmacological and surgical management of PPH is primarily based on the guidelines set by
the MoreOB program of the Society of Obstetricians and
Gynaecologists of Canada,8 and the perioperative transfusion of blood products follows the Health Canada guidelines.9 The transfusion data, in the form of transfusion of
packed red blood cells, fresh frozen plasma, platelets,
cryoprecipitate or recombinant factor VII, were reviewed in
all cases. We recorded patient outcomes in the form of
immediate and delayed morbidity and mortality as a result
of major PPH and blood transfusion.
Ethics approval for this study was obtained from the
Research Ethics Board at Mount Sinai Hospital.
RESULTS

During the study period, 33 631 patients delivered at our

institution. Of these, 23 478 patients (70%) delivered vaginally, 5073 (15%) delivered by CS during labour, and 5080
(15%) delivered by elective CS before labour. The overall
incidence of primary PPH was 3.2% (1078/33 631). Blood
transfusion within 24 hours of delivery was required in
0.31% of the patients (104/ 33 631). The blood transfusion
rate was highest in the patients requiring CS during labour
(0.49%, or 25/5073), compared with 0.28% (67/23478) in
those who delivered vaginally, and 0.23% (12/5080) in
those who had elective CS before labour. In patients who
experienced labour, blood transfusion was more commonly
required in those with spontaneous labour (48%) than in
those with induced (26%) or augmented labour (26%).
Normal placentation was present in the majority of patients
(83%). Sixty-seven percent of patients with abnormal
placentation were delivered by CS. The principal causes of
PPH were uterine atony (38.5%) and retained products of
conception (33.7%) (Table 1). The risk factors for PPH
could be identified antenatally in 61% of patients, and are
shown in Table 2. The remaining 39% of patients receiving
blood transfusions had one or more intrapartum risk
factors for PPH.
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OBSTETRICS

Table 1. Demographics, obstetric details, and etiology of postpartum hemorrhage requiring blood
transfusion
Total
(n = 104)

Vaginal deliveries
(n = 67)

Elective CS
(n = 12)

CS during labour
(n = 25)

Demographics
Age in years, SD

33.6 4.8

33.3 4.9

35.0 5.0

33.7 4.8

Weight in kg, SD

75.9 13.3

75.4 13.7

78.9 15.7

75.6 8.6

Gestational age in weeks SD

35.8 6.1

35.0 7.0

37.3 2.2

36.9 4.7

Primipara, n (%)

56 (53.8)

38 (56.7)

3 (25)

15 (60)

Multipara, n (%)

48 (46.2)

29 (43.3)

9 (75)

10 (40)

Spontaneous

44 (47.8)

33 (49.2)

11 (44)

Induced

24 (26.1)

16 (23.9)

8 (32)

Augmented

24 (26.1)

18 (26.9)

6 (24)

Labour (n = 92), n (%)

Prolonged first stage

12 (13)

12 (52)

Prolonged second stage

6 (6.5)

4 (6.0)

2 (8)

Prolonged third stage

1 (1.1)

1(1.5)

Normal

86 (82.6)

61 (91)

6 (50)

19 (76)

Previa

7 (6.7)

2 (3)

2 (16.7)

3 (12)

Accreta

7 (6.7)

4 (6)

1 (8.3)

2 (8)

Percreta

3 (2.9)

3 (25)

Abruption

1 (0.9)

1 (4)

Atony

40 (38.5)

18 (26.9)

5 (41.7)

17 (68)

Retained tissues

35 (33.7)

28 (41.8)

5 (41.7)

2 (8)

Genital tract trauma

13 (12.5)

12 (17.9)

1 (8.3)

Coagulopathy

7 (6.7)

4 (6.0)

3 (12)

Undetermined

9 (8.7)

5 (7.5)

1 (8.3)

3 (12)

Placentation, n (%)

Etiology of PPH, n (%)

The mean lowest hemoglobin concentration during bleeding was 63 15 g/L, the mean lowest hematocrit was 0.19
0.44%, and the mean lowest platelet count was 128 000
74 000/mm3 (Table 3). All patients received transfusions of
PRBCs (median 3 units; 900 mL). Recombinant factor VII
was administered in one patient. The use of other blood
products is shown in Table 4. Details of the uterotonic
agents used are shown in Table 5. All four uterotonic agents
(oxytocin, ergometrine, carboprost, and misoprostol) were
administered concomitantly in only 20% of the cases, while
about 50% of the patients received an additional drug other
than oxytocin. Dilatation and curettage (26.9%) and manual
removal of the placenta (17.3%) were the most common
surgical procedures performed, and hysterectomy and gel
foam embolization of uterine arteries were each performed
in 16.3% of patients (Table 5).
Invasive monitoring with arterial line and central vein
cannulation was carried out in 37.5% and 14.4% of patients,
respectively, and both of these procedures were used in
1004 l NOVEMBER JOGC NOVEMBRE 2008

12.5% of patients. Twenty percent of patients developed

coagulopathy including disseminated intravascular coagulation, and 24% required admission to the intensive care unit.
Pulmonary complications were observed in 2.8% of
patients, and cardiac complications were observed in 1%.
No deaths occurred in this series.
DISCUSSION

Despite improvements in management strategies, PPH

remains one of the leading causes of maternal morbidity
and mortality worldwide.1 The United Kingdom Confidential Enquiry into Maternal Deaths in 20002002 reported
17 deaths due to hemorrhage, compared with seven in the
previous triennium; 10 were due to PPH, compared with
one in the previous report.10 A recent population-based
prospective study in Scotland and a study in Nova Scotia
reported hemorrhage to be the most important cause of
major obstetric morbidity, accounting for more than 50%
of the overall incidence.11,12

Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review

Table 2. Antenatal risk factors for postpartum

hemorrhage requiring blood transfusion
Risk factors

n (%)

Previous uterine surgery

22 (21.2)

Antepartum hemorrhage

21 (20.1)

Multiple gestation

18 (17.3)

Macrosomia

17 (16.3)

Abnormal placentation

17 (16.3)

Pregnancy induced hypertension

14 (13.5)

Chorioamnionitis

9 (8.7)

Blood disorders/anticoagulation

8 (7.7)

History of PPH

5 (4.8)

In our study, the patients requiring blood transfusion represented only 10% of the total patients with PPH. The incidence of transfusion for primary PPH (occurring within 24
hours of delivery) was 0.31%. This result is consistent with
the data of Reyal et al., which showed a frequency of transfusion of 0.23% during the period 19921998.13 The rates
of blood transfusion vary in different institutions because
of a great variance in physicians attitudes toward blood
transfusions. Ransom et al. reported a frequency of transfusion of 0.47% in patients undergoing vaginal deliveries, but
Rouse et al. found a rate of 3.2% in patients having a primary CS and 2.2% in those having a repeat CS.14,15 This
high incidence of transfusion could perhaps be due to lack
of standardized transfusion strategies in the authors institution. Various national health care organizations have introduced new policy guidelines for PRBC transfusions,1618 as
a result of which there has been an overall decline in the
number of PRBC transfusions in the current decade.19
Despite this low rate of transfusion in our patient population, morbidity in the form of DIC, cardiac and pulmonary
complications, and a need for ICU admission was seen in
about 32% of patients requiring blood transfusion. The
markers for this major maternal morbidity were the transfusion of more than five units of PRBCs, emergency hysterectomy, and/or uterine artery embolization.
The results of our study prompted us to review the current
protocols for the pharmacologic and surgical management
of PPH in order to minimize the risk for potential blood
transfusions. The prophylactic administration of oxytocin
after delivery is the current standard for prevention of PPH,
because of its rapid onset of action and the lack of serious
adverse effects if administered appropriately.20 Nevertheless, in clinical practice this drug is often administered in
excessive amounts, especially in the event of postpartum
bleeding, which can lead to several undesirable
hemodynamic effects such as hypotension and circulatory

collapse.2123 On the other hand, other uterotonic drugs are

still underused despite ready availability in most centres. In
the current study, all four uterotonic agents available at our
institution (oxytocin, ergometrine, carboprost, and
misoprostol) were concomitantly administered in only 20%
of the cases, while only about 50% of the patients received
an additional drug other than oxytocin.
Interestingly, we found a twofold increase in the requirement for blood transfusion (0.49%) in patients undergoing
CS during labour compared with those undergoing elective
CS (0.23%). These results are concurrent with our previous
findings that labouring patients undergoing CS had approximately twice the amount of blood loss experienced by
non-labouring patients undergoing CS.24,25 In accordance
with the literature, this can be attributed to the inappropriate myometrial response to oxytocin arising from
oxytocin-receptor desensitization due to prolonged
oxytocin exposure during labour.26,27 This effect is likely to
be exaggerated in patients with induced or augmented
labours, and, although not significantly observed in our
study population, one would predict a higher incidence of
hemorrhage in this subset of patients, on the basis of clinical
trials and biomolecular studies on oxytocin-receptor desensitization.24,27 Thus, the labouring uterus is likely to be less
responsive to the administration of further oxytocin after
delivery; hence, in the event of postpartum bleeding, the
timely use of additional uterotonics that act via pathways
other than oxytocin receptors is certainly desirable.
Although uterine atony was the most common etiology in
our patients, retained products of conception also
accounted for a large number of patients with postpartum
bleeding requiring blood transfusion. The higher incidence
of retained placenta in elective CS patients (42%) can be
attributed to abnormal placentation or previous uterine surgery in these patients. In a study of 154 311 deliveries,
Sheiner et al. found retained placenta to be the most significant risk factor for PPH (OR 3.5; 95% CI 2.15.8).28 Some
aspects of the obstetrical techniques used warrant reassessment in light of this finding. These include the careful management of the third stage of labour in vaginal deliveries to
decrease the incidence of retained placental tissue, and
allowing spontaneous placental delivery during CS. The
approach of waiting for the uterine fundus to contract at CS
and allowing the spontaneous expulsion of the placenta,
rather than removing it manually, has been shown to
decrease total blood loss.29 Recently, the injection of
uterotonic agents into the umbilical vein has shown to be a
non-invasive, effective, and clinically safe method of
reducing the rate of placentas remaining undelivered
beyond 15 minutes, and of minimizing the subsequent
blood loss.30,31 Inspection of the placenta for completeness
NOVEMBER JOGC NOVEMBRE 2008 l 1005

OBSTETRICS

Table 3. Blood work during postpartum hemorrhage

Parameter

Baseline

Lowest

Post-transfusion

Hemoglobin, g/L

117 15

63 15

91 15

0.35 0.42

0.19 0.44

0.27 0.44

Platelets, 000/mm3

216 84

128 74

170 81

INR

1.0 0.1

1.4 0.9

1.1 0.1

Hematocrit, %

Values expressed as mean SD

Table 4. Transfusion data

Number of patients (%)

Median units (range)

Packed red blood cells

104 (100)

3 (126)

Fresh frozen plasma

44 (42.3)

4 (122)

Platelets

19 (18.2)

5 (120)

Cryoprecipitate

10 (9.6)

5.5 (115)

1 (1)

Blood products

Recombinant Factor VII

Table 5. Pharmacological and surgical management of postpartum hemorrhage

Number of patients (%)

Mean dose SD

Drugs
104 (100)

47 19

59 (57)

450 260

Carboprost (mg)

51 (49)

730 421

Misoprostol (mg)

25 (24)

976 167

Oxytocin (IU)
Ergometrine (mg)

Surgical Procedures
Dilatation and curettage

28 (26.9)

Manual removal of placenta

18 (17.3)

Hysterectomy

17 (16.3)

Uterine artery embolization

17 (16.3)

Repair of lacerations

14 (13.5)

Uterine artery ligation

6 (5.8)

Uterine compression suture

3 (2.9)

and early detection of retained tissue by the use of ultrasound may help to reduce the incidence of retained
products of conception after delivery.

accessible, and its high incidence of use in our patient

population indicates its efficacy.

The application of uterine compression sutures, such as

B-Lynch sutures or their modifications, is a simple, conservative procedure to stop hemorrhage and has been shown
to obviate the need for hysterectomy.32,33 However, in our
study, these sutures were applied in only 3% of the patients
receiving blood transfusions. Hysterectomy is the last resort
in the management of PPH unresponsive to oxytocic drugs
or other conservative methods.7 Uterine artery
embolization is an alternative to hysterectomy in institutions where interventional radiology services are readily

Our study was not intended to identify risk factors for PPH,
since these have already been described; rather, we compiled common characteristics seen in patients with major
bleeding episodes requiring blood transfusions. The current
study was also limited by the retrospective data collection
and a lack of case-control design; however, it gives us a profile of the patients requiring blood transfusions postpartum,
and it provides details of the pharmacological management,
transfusion requirements and patient outcomes in these
patients, which have not been described previously.

1006 l NOVEMBER JOGC NOVEMBRE 2008

Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review

CONCLUSION

The incidence of postpartum blood transfusion for primary

PPH at our institution is low, and the majority of high-risk
patients can be identified with careful antenatal examination. However, many patients develop risk factors for PPH
during labour, and those developing severe complications
postpartum are often difficult to identify before delivery.
Hence, vigilant monitoring of patients to identify risk factors for bleeding during the peripartum period is necessary
for more effective planning of resources and better clinical
management. An aggressive prophylactic pharmacological
approach and early recognition of retained products of conception are vital to reduce the incidence of blood transfusions and to prevent life-threatening complications. We
encourage other practitioners to review their own practices
in regard to the management of PPH and blood
transfusion.
ACKNOWLEDGEMENTS

This paper was presented as a poster at the Society for

Obstetric Anesthesia and Perinatology Meeting, Hollywood, Florida, USA, April 2630, 2006.
The authors acknowledge Kristi Downey (Research Assistant) for organizing the database and Dr John Kingdom
(Professor of Obstetrics and Gynaecology, University of
Toronto) for reviewing the manuscript.
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