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Over the past 40 years, deaths from haemorrhage have fluctuated (Figure 2.1), which may represent relaxation and tightening of standards. For example, the peak in 1988–1990 included cases where doctors had ignored the recommendation that CS for placenta praevia should be carried out by a consultant.

Figure 2.1 Deaths from haemorrhage reported to the CEMDs, 1976–2018

It is important, however, to see these numbers in context. Haemorrhage is by far the most common life‐threatening complication of childbirth: surveys of severe morbidity show that haemorrhage of >2.5 litres occurs once in about 300 births. Therefore over a 3‐year period with more than 2 million births in the UK, several thousand cases are treated successfully.

In 2016–2018, the total of 14 deaths due to haemorrhage included two cases of uterine atony, three of morbidly adherent placenta, three of abruption, two of uterine inversion and four of genital tract trauma. In 79% of cases there was room for improvements in care, and the main messages focused on:Ensuring a senior clinician takes a ‘helicopter view’ of the management of a woman with major obstetric haemorrhage to coordinate all aspects of care

 Early recognition (especially when haemorrhage is concealed) including awareness of the signs of uterine inversion

 Ensuring that the response to obstetric haemorrhage is tailored to the proportionate blood loss as a percentage of circulating blood volume based on a woman’s body weight

 Early correction of coagulopathy

 Progressing to hysterectomy when bleeding is uncontrolled, particularly from a morbidly adherent placenta or uterine rupture

Every triennium, one or more deaths occur in women who refuse blood transfusion and guidelines have been issued about the management of such patients. Placenta praevia associated with a uterine scar is particularly dangerous and all women with a previous CS should have a scan for placental localisation in the second trimester and, if low lying, again at 32 weeks.