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Postpartum haemorrhage: a single definition is no longer enough

During a WHO ‘informal meeting of experts’ in 1989, PPH was defined as ‘the loss of 500mls or more of blood from the genital tract after delivery of the baby’. This definition has been widely cited, and has been relatively unchallenged until recently, despite the meeting’s report acknowledging 500 ml as ‘an arbitrary figure’ and ‘not always of great clinical significance’. In recent years, professional societies have developed definitions with more clinical significance. The Royal College of Obstetricians and Gynaecologists (RCOG) in 2011 endorsed the 500 ml threshold in their definition of ‘Minor PPH’, although it stated that 1000 ml (or a lesser volume with clinical shock), should be classed as ‘Major PPH’. They recommend ‘readiness for resuscitation’ in response to blood loss 500–1000 ml, but ‘a full protocol of measures’ when the blood loss reaches 1000 ml or there are clinical signs of shock. The American College of Obstetricians and Gynecologists (ACOG) held a modified Delphi vote of its members in 2014 to reach a consensus on a PPH definition. They dismissed the 500 ml cutoff, endorsing in its place a definition of ‘greater or equal to 1000 ml or blood loss with signs or symptoms of hypovolemia’. The WHO avoided a specific recommendation in their 2012 guidelines, instead commenting that ‘PPH is commonly defined as blood loss 500 ml or more’. The most recent WHOendorsed definition was instead for ‘Severe PPH’, defined by the WHO Working Group on Maternal Mortality and Morbidity Classifications as ‘genital bleeding after delivery, with at least one of the following: perceived abnormal bleeding (1000 ml or more) or any bleeding with hypotension or blood transfusion’.