Causes of PPH: Obstetric Myths versus Midwifery Reality Anne Saxton, Professor K. Fahy, Dr Virginia Skinner University of Newcastle PPH rates currently around 25% in tertiary centres. Obstetricians believe that PPH can be explained by these causes: Previous history of primary postpartum haemorrhage Abnormal uterine anatomy: e.g. Fibroids previous uterine surgery . Over distended uterus: e.g. multiple gestation, polyhydramnios. Parity of 6 or greater Abnormalities of the placenta: e.g. previa Antepartum or Intrapartum haemorrhage Haemoglobin of less than 110 gm per litre Abnormalities of coagulation Obstetric or anaesthetic interventions: e.g. induction, augmentation, epidurals, forceps, vacuum, shoulder dystocia, episiotomy or tear requiring suturing. Uterine muscle exhaustion: due to prolonged labour Intra amniotic infection Drug induced uterine hypotonia: e.g. magnesium sulphate, nifedipine and salbutamol Obesity: BMI > 25 References: Bateman, B., M. Berman, et al. (2010). "The epidemiology of postpartum haemorrhage in a large, nationwide sample of deliveries." Society for Obstetric Anesthesia and Perinatology 110(5): 1368-1373. Cunningham, F., N. Gant, et al. (2001). Williams Obstetrics. London, McGraw- Hill. Zhang, J., L. Bricker, et al. (2007). "Poor uterine contractility in obese women." BJOG: An International Journal of Obstetrics & Gynaecology 114(3): 343-348. Midwifery Reality: for women at low risk of PPH the 'obstetric causes’ fail to explain 84% of all PPH. The major causes of PPH are iatrogenic: i.e. interfering in reproductive psychophysiology Midwifery Understanding of the ‘causes’ of PPH A 'surveillance room' for birth i.e. cold, noisy, brightly lit room with strangers or unwanted people in room The woman is ill prepared and does not understand that she is still in labour until the placenta is born Attitude of midwife is not warm and supportive Partner/support people interactions are not focussed on the woman The woman does not feel that she is in a safe and supportive environment The attending midwife does not know how to act as a midwifery guardian Labour and birth of baby were disturbed by intervention/other The woman and her baby are separated at end of second stage Immediate and sustained skin-to skin contact is not initiated Breastfeeding is not initiated There is fundal meddling or massage during 3rd stage References Fahy, F., C. Hastie, et al. (2010). "Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study." Women & Birth. Fahy, K., M. Foureur, et al., Eds. (2008). Birth territory and midwifery guardianship: theory for practice, education and research. London, Butterworth Heinemann. Fahy, K. M. (2009). "Third stage of labour care for women at low risk of postpartum haemorrhage." Journal of Midwifery & Women's Health. 54(5): 380-386. Odent, M. (1998). "Don't manage the third stage of labour!" The Practising Midwife 11(9): 31-33.