Introduction

Article Outline

• Copyright

It is a widely accepted sentiment that “it takes a village to raise a child.” It may be just as appropriate to state that it takes a team to deliver a baby. This may be most appropriate when reviewing the management of obstetric hemorrhage. In this issue of Seminars in Perinatology, we will present a clinical review of obstetric hemorrhage. This review will include a discussion of management options, many of which are focused on preparedness and team development.

Improvements in medical and surgical care have resulted in significant advances in the quality of maternal health. Consequently, it is extremely rare for a woman to die in childbirth. However, even though it is a rare event that death will have a devastating impact on the life of the surviving infant and the family that is left behind to care for the child. Obstetric hemorrhage remains the most common cause of maternal mortality worldwide. Although this risk is greatest for women in the undeveloped world, all women remain at risk. In those cases of significant hemorrhage that don't result in maternal death, the patient still remains at risk for significant morbidity.

It is of great concern that many countries are reporting an increase in the incidence of obstetric hemorrhage. A single unifying cause cannot be identified; however, many of the clinical factors that place a patient at risk are increasing in frequency. The incidence of multiple gestations has risen dramatically in direct response to the success of artificial reproductive technologies. The cesarean delivery rate has increased nearly 50% over the past decade to a record high of greater than 30%. Clinical trends, such as delay in child bearing, increased number of multiples, and the decline in VBAC and operative vaginal deliveries, will combine to keep the cesarean section rate at this level, if not higher.

Although outcomes have improved in the setting of obstetric hemorrhage, there is reason to believe that we can do better. There is an evolving body of literature that indicates that a large percentage of hemorrhage cases may be prevented or the outcomes improved with better management. Columbia University Medical Center has adopted a team approach to the management of hemorrhage. Specific members of our team have authored these chapters with the goal of sharing their expertise in a given area. This issue of Seminars in Perinatology provides a detailed clinical review of the etiology, pathophysiology, prevention and management of obstetric hemorrhage. It includes a review of the medications commonly used to minimize blood loss at the time of delivery. Operative considerations, such as uterine-sparing techniques, cesarean hysterectomy, and hemostatic agents, are discussed. In addition, issues related to the management of anesthesia for these cases and trends in transfusion medicine are reviewed. We conclude with a discussion of the potential role of patient safety initiatives and simulation training in improving outcomes in the management of obstetric hemorrhage.

We would like to express our thanks to Drs. D'Alton and Gross for the opportunity to be guest editors for this issue. It is our sincere hope that the reader will find this issue informative, and that it will prove useful as we move forward to develop better systems to optimize management and improve outcomes for cases of obstetric hemorrhage.