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Many women have a risk factor for postpartum hemorrhage, a leading cause of maternal morbidity and mortality. One significant morbidity is a postpartum hemorrhage resulting in the need for transfusion. We sought to determine risk factors for postpartum hemorrhage to determine which might be modifiable and find a solution to reduce the need for peripartum transfusion.

Postpartum hemorrhage occurs in 4-6% of deliveries, and results in peripartum transfusion in between 0.4-1.6% of deliveries (ACOG, 2006). Transfusion carries its own risks, such as infectious disease transmission, transfusion reactions, volume overload, and lung injury. (Katz, 2009). Previous research has demonstrated the increased risk of transfusion associated with cesarean delivery (CD), especially multiple repeat CD, placenta previa, general anesthesia, and anemia (Rouse et al, 2006). We chose to look at all deliveries to determine risk factors for hemorrhage resulting in transfusion. This was a retrospective study of women delivering at a large regional obstetrical hospital between 2000 and 2008. We used only the data on the most recent pregnancy for each woman. We excluded those women who had another disorder which might increase the need for transfusion, such as sickle cell, thalassemia, thrombocytopenia, or preeclampsia. Data collected included maternal age, race/ethnicity, medical risks, obstetrical history, and delivery details. Chi-squared and logistic regression were used to identify risk factors for peripartum transfusion

There were 51,411 deliveries with valid, retrievable data. Of this population, 63% were Caucasian, 21.7% Black, 9.2% Hispanic, 4.4% Asian, 0.5% American Indians with 1.2% unknown. Mode of delivery was 70.7% vaginal (2% VBAC) and 29.2% cesarean. The mean age of parturients was 28 years, while gestational age at delivery was 38 weeks. The incidence of postpartum transfusion in the year 2000 was 0.6%, but by 2005 had risen by 100% to a rate of 1.2%. Risk factors significant for postpartum transfusion included multiple gestation, (AOR 4.61, 95% CI 3.6-5.9, p<0.0001), cesarean delivery, (AOR 4.29, 95% CI 3.55-5.19, p<0.0001), and most notably maternal pre-delivery anemia (hemoglobin < 10.5 mg/dL), with AOR 4.89, 95% CI 4.00-5.98, p<0.0001.

Transfusion was significantly higher for women with anemia upon admission. Anemia, defined as Hgb less than 10.5 mg/dl, complicates 21% of pregnancies in the United States. During prenatal care, it is standard of care to screen for anemia, as it allows time to identify and treat (ACOG, 2008). The most common is iron-deficiency anemia, which may be confirmed by a serum ferritin level and treated by a combination of diet modification and iron & vitamin C supplementation (Milman, 2008). When a woman is diagnosed with anemia and given iron, Hgb should be reassessed to verify response/compliance. If anemia continues, further care is warranted: counseling regarding adherence, increased iron, consideration of intravenous iron, and further evaluation for other causes of anemia (Alleyne, Horne, & Miller, 2008). Women’s health and obstetric nurses provide preconception education and prenatal care, both ideal opportunities to ensure women with anemia receive follow-up care, thus potentially having significant impact on the risk of peripartum transfusion.