The increasing role of a retained placenta in postpartum blood loss: a cohort study

  • Hellen McKinnon EdwardsEmail author
  • Jens Anton Svare
  • Anne Juul Wikkelsø
  • Jeannet Lauenborg
  • Jens Langhoff-Roos
Maternal-Fetal Medicine



To describe the association between quantity of blood loss, duration of the third stage of labour, retained placenta and other risk factors, and to describe the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage.


Cohort study of all vaginal deliveries at two Danish maternity units between 1 January 2009 and 31 December 2013 (n = 43,357), univariate and multivariate linear regression statistical analyses.


A retained placenta was shown to be a strong predictor of quantity of blood loss and duration of the third stage of labour a weak predictor of quantity of blood loss. The predictive power of the third stage of labour was further reduced in the multivariate analysis when including retained placenta in the model. There was an increase in the role of a retained placenta depending on the cutoff used to define postpartum haemorrhage, increasing from 12% in cases of blood loss ≥ 500 ml to 53% in cases of blood loss ≥ 2000 ml


The predictive power of duration of the third stage of labour in regard to postpartum blood loss was diminished by the influence of a retained placenta. A retained placenta was, furthermore, present in the majority of most severe cases.


Postpartum haemorrhage Retained placenta Third stage of labour Pregnancy blood loss 



We would like to thank Steen Rasmussen and Tobias W. Klausen for their contribution to data extraction and statistical analyses.

Author contributions

HME: project development, data collection, data analysis, and manuscript writing. JL-R: project development, data collection, data analysis, and manuscript editing. AJW: project development and manuscript editing. JAS: project development and manuscript editing. JL: project development and manuscript editing.


This study received funding from the Department of Obstetrics and Gynaecology, Herlev Hospital, Denmark.

Compliance with ethical standards

Conflicts of interest

HE, JL, AW, JS, and JLR declare that we have no conflicts of interest or financial ties to disclose.

Ethical approval

This study fulfils all Danish ethical standards and was approved by the Danish Data Protection Agency (No. 2012-58-0004).

Supplementary material

404_2019_5066_MOESM2_ESM.docx (23 kb)
Supplementary file1 Univariate linear regression analysis of risk factors for prediction of quantity of postpartum blood loss after vaginal delivery [proportions and percent (%) are depicted for categorical data and medians and interquartile ranges (IQR) for non-normally distributed data] (DOCX 20 kb)
404_2019_5066_MOESM1_ESM.docx (20 kb)
Supplementary file2 Multivariate linear regression analysis of all models for prediction of quantity of postpartum blood loss after vaginal delivery [proportions and percent (%) are depicted for categorical data and medians and interquartile ranges (IQR) for non-normally distributed data] (DOCX 23 kb)


  1. 1.
    Say L, Chou D, Gemmill A et al (2014) Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2:e323–e333. CrossRefGoogle Scholar
  2. 2.
    Knight M, Callaghan WM, Berg C et al (2009) Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 9:55. CrossRefGoogle Scholar
  3. 3.
    Bateman BT, Berman MF, Riley LE, Leffert LR (2010) The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 110:1368–1373. CrossRefGoogle Scholar
  4. [4]
    WHO, UNICEF, UNFPA TWB and the UNPD WHO | Trends in Maternal Mortality: 1990 to 2015. World Health Organization, 2015. []. In: Last accessed 20 July 2016
  5. 5.
    Kramer MS, Berg C, Abenhaim H et al (2013) Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 209:449.e1–7. CrossRefGoogle Scholar
  6. 6.
    Rossen J, Økland I, Nilsen OB, Eggebø TM (2010) Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions? Acta Obstet Gynecol Scand 89:1248–1255. CrossRefGoogle Scholar
  7. 7.
    Anderson JM, Etches D (2007) Prevention and management of postpartum hemorrhage. Am Fam Physician 75:875–882Google Scholar
  8. 8.
    Oyelese Y, Ananth CV (2010) Postpartum Hemorrhage: Epidemiology, Risk Factors, and Causes. Clin Obstet Gynecol 53:147–156. CrossRefGoogle Scholar
  9. 9.
    Howard TF, Grobman WA (2015) The relationship between timing of postpartum hemorrhage interventions and adverse outcomes. Am J Obstet Gynecol 213:239.e1–e3. CrossRefGoogle Scholar
  10. 10.
    Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B (2008) Prevalence and risk factors of severe obstetric haemorrhage. BJOG 115:1265–1272. CrossRefGoogle Scholar
  11. [11]
    The Danish Society of Obstetrics and Gynaecology Guideline for Postpartum Haemorrhage. Denmark: DSOG, 2013 []. In: Last accessed 20 June 2016
  12. [12]
    Royal College of Obstetricians and Gynaecologists Postpartum Haemorrhage, Prevention and Management (Green-top Guideline No52). London: RCOG, 2011. []. In: Last accessed 20 June 2016
  13. 13.
    Sosa CG, Althabe F, Belizán JM, Buekens P (2009) Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population. Obstet Gynecol 113:1313–1319. CrossRefGoogle Scholar
  14. 14.
    Magann EF, Evans S, Chauhan SP et al (2005) The length of the third stage of labor and the risk of postpartum hemorrhage. Obstet Gynecol 105:290–293. CrossRefGoogle Scholar
  15. 15.
    Frolova AI, Stout MJ, Tuuli MG et al (2016) Duration of the third stage of labor and risk of postpartum hemorrhage. Obstet Gynecol 127:951–956. CrossRefGoogle Scholar
  16. 16.
    Magann EF, Niederhauser A, Doherty DA et al (2012) Reducing hemodynamic compromise with placental removal at 10 versus 15 Minutes: a randomized clinical trial. Am J Perinatol 29:609–614. CrossRefGoogle Scholar
  17. 17.
    Shinar S, Shenhav M, Maslovitz S, Many A (2016) Distribution of third-stage length and risk factors for its prolongation. Am J Perinatol 33:1023–1028. CrossRefGoogle Scholar
  18. 18.
    Krapp M, Baschat AA, Hankeln M, Gembruch U (2000) Gray scale and color Doppler sonography in the third stage of labor for early detection of failed placental separation. Ultrasound Obstet Gynecol 15:138–142. CrossRefGoogle Scholar
  19. 19.
    Herman A (2000) Complicated third stage of labor: time to switch on the scanner. Ultrasound Obstet Gynecol 15:89–95. CrossRefGoogle Scholar
  20. 20.
    Brixval CS, Thygesen LC, Johansen NR et al (2015) Validity of a hospital-based obstetric register using medical records as reference. Clin Epidemiol 7:509–515. CrossRefGoogle Scholar
  21. 21.
    Henriksen DP, Rasmussen L, Hansen MR et al (2015) Comparison of the five danish regions regarding demographic characteristics, healthcare utilization, and medication use—a descriptive cross-sectional study. PLoS ONE 10:e0140197. CrossRefGoogle Scholar
  22. 22.
    Buzaglo N, Harlev A, Sergienko R, Sheiner E (2015) Risk factors for early postpartum hemorrhage (PPH) in the first vaginal delivery, and obstetrical outcomes in subsequent pregnancy. J Matern Neonatal Med 28:932–937. CrossRefGoogle Scholar
  23. 23.
    Sheiner E, Sarid L, Levy A et al (2005) Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med 18:149–154. CrossRefGoogle Scholar
  24. 24.
    Sheldon WR, Blum J, Vogel JP et al (2014) Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG 121:5–13. CrossRefGoogle Scholar
  25. 25.
    Liu L, Hong Z, Zhang L (2015) Associations of prepregnancy body mass index and gestational weight gain with pregnancy outcomes in nulliparous women delivering single live babies. Sci Rep 5:1–9. Google Scholar
  26. 26.
    Dilla AJ, Waters JH, Yazer MH (2013) Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet Gynecol 122:120–126. CrossRefGoogle Scholar
  27. 27.
    Ekin A, Gezer C, Solmaz U et al (2015) Predictors of severity in primary postpartum hemorrhage. Arch Gynecol Obstet 292:1247–1254. CrossRefGoogle Scholar
  28. 28.
    Bais JM, Eskes M, Pel M et al (2004) Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women: A Dutch population-based cohort study on standard (≥500 ml) and severe (≥1000 ml) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 115:166–172. Google Scholar
  29. 29.
    Fitzpatrick KE, Sellers S, Spark P et al (2014) The management and outcomes of placenta accreta, increta, and percreta in the UK: A population-based descriptive study. BJOG 121:62–70. CrossRefGoogle Scholar
  30. 30.
    Rac MW, Dashe JS, Wells CE et al (2015) Ultrasound predictors of placental invasion: the placenta accreta index. Am J Obstet Gynecol 212:343. Google Scholar
  31. 31.
    Akol AD, Weeks AD (2016) Retained placenta: will medical treatment ever be possible? Acta Obstet Gynecol Scand 95:501–504. CrossRefGoogle Scholar
  32. 32.
    Ramu S, Stamatkin C, Timms L et al (2013) PreImplantation factor (PIF) detection in maternal circulation in early pregnancy correlates with live birth (bovine model). Reprod Biol Endocrinol 11:105. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Obstetrics and GynaecologyCopenhagen University Hospital HerlevHerlevDenmark
  2. 2.Department of Anaesthesia and Intensive Care MedicineCopenhagen University Hospital HerlevHerlevDenmark
  3. 3.Department of ObstetricsJuliane Marie Centre, RigshospitaletCopenhagenDenmark

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