BACKGROUND AND PURPOSE: 

• Previous studies that assessed the relationship between time of day and postpartum hemorrhage (PPH) outcomes have focused on cesarean delivery and frequency of PPH rather than morbidity
• Yee et al. (Obstetrics & Gynecology, 2018) examined whether postpartum hemorrhage is managed differently and had different outcomes during the day or night

METHODS: 

• Secondary analysis of a multicenter observational obstetric cohort of mother–neonate pairs  
  • NICHD/ MFMU network study
• Original study: Assessment of Perinatal Excellence 
  • 115,502 women and their neonates (deliveries between 2008 to 2011) 
• For this present study
  • Inclusion criteria: Women had delivered singleton or twin births  
  • Postpartum hemorrhage defined as  
    • EBL >500 cc for vaginal delivery 
    • EBL >1,000 cc for cesarean delivery 
    • Treatment for PPH 
• Nighttime delivery: Between 8 PM and 6 AM 
• Primary outcome  
  • Composite of maternal morbidity 
    • Death | Hysterectomy | ICU admission | Transfusion | Unanticipated procedure for bleeding 
• Secondary outcomes  
  • EBL | Uterotonic use | Procedures to treat postpartum bleeding

RESULTS: 

• 7917 women with PPH  
  • 2,709 (34.2%) delivered at night 
  • Vaginal delivery: 5.3%  
  • Cesarean: 10.5%  
• Women who delivered at night 
  • Were younger 
  • Had a lower body mass index 
  • Were more likely to have government-sponsored insurance 
  • Be nulliparous 
  • Have hypertension 
  • Use neuraxial analgesia 
  • Deliver vaginally 
• After adjusting for potential confounders, there was no significant difference in primary composite outcome  
  • 15.5% night vs 17.5% day 
  • adjusted odds ratio (OR) 0.89 (95% CI, 0.77–1.03) 
• Secondary outcome differences likewise did not show statistically significant differences in adjusted analyses

CONCLUSION: 

• In this diverse cohort, after adjusting for variables, no significant association was identified between time of day of delivery and PPH morbidity or specific interventions  
• Limitations include 
  • Change in PPH definition in 2017, after the Assessment of Perinatal Excellence study was completed  
  • Underpowered to assess maternal death or uncommon surgical interventions, including hysterectomy  
  • Sites were at academic centers and therefore may not be generalizable  
    • E.g. ‘float’ system for residents  
• The authors state 

Such findings suggest women and their health care providers can be reassured that time of delivery does not appear to compromise care or outcomes for this obstetric emergency. 

Learn More – Primary Sources: 

Daytime Compared With Nighttime Differences in Management and Outcomes of Postpartum Hemorrhage

Related ObG Topics:

Postpartum Hemorrhage – Medications to Treat Uterine Atony 

Does ART Increase Risk of Postpartum Hemorrhage?

How Effective is Intrauterine Balloon Tamponade for Severe Postpartum Hemorrhage