Mode of Delivery and Postpartum Hemorrhage: A Comparative Analysis of Risk Factors and Outcomes.

Postpartum hemorrhage (PPH) is an obstetric emergency and the leading cause of maternal mortality worldwide, accounting for nearly one-quarter of all maternal deaths. The traditional definition of PPH is an estimated blood loss of ≥500 mL after a vaginal delivery or ≥1000 mL after a cesarean section within 24 hours of birth.

In India, despite significant improvements in institutional delivery rates, PPH continues to burden the healthcare system, particularly in high-volume tertiary care centers that receive late-stage referrals. Maharaja Krishna Chandra Gajapati Medical College and Hospital (MKCG MCH) in Berhampur serves as a crucial referral hub for southern Odisha. The shifting obstetric landscape, characterized by rising cesarean section rates, has altered the traditional risk factor profile of PPH. This study aims to evaluate and compare the risk factors, causes, and maternal outcomes of PPH in women undergoing vaginal versus cesarean deliveries over a one-year period.

This prospective observational study was conducted in the Department of Obstetrics and Gynecology at MKCG MCH, Berhampur, over one year (March 2025 to March 2026). The final sample size consisted of 126 women who met the clinical criteria for primary PPH.

·         Inclusion Criteria: All women delivering at or referred to MKCG MCH within 24 hours postpartum who experienced primary PPH.

·         Data Collection: Detailed histories were recorded, including demographics, booking status, parity, mode of delivery, estimated blood loss, interventions required, and clinical outcomes.

·         Statistical Analysis: Data were tabulated and analyzed using SPSS software. Categorical variables were expressed as frequencies and percentages. The Chi-square test was used to compare the variables between the vaginal and cesarean groups. A p-value of <0.05 was considered statistically significant.

The study cohort consisted of 126 women, of which 74 (58.7%) experienced PPH following a vaginal delivery (VD), and 52 (41.3%) following a cesarean section (CS).

Table 1: Distribution of Primary Causes of PPH Uterine atony was the primary driver of PPH across both groups. However, retained tissue and abnormal placentation were significantly more prevalent in women who underwent cesarean sections.

Table 2: Antenatal and Intrapartum Risk Factors Anemia was a widespread baseline risk factor. Prolonged labor was a strong predictor for VD-associated hemorrhage, whereas placental anomalies dictated CS-associated hemorrhage.

Table 3: Medical and Mechanical Interventions Both groups received standard uterotonic therapy as first-line management. The need for blood transfusions was high in both cohorts, reflecting the severity of cases referred to this tertiary center.

Table 4: Surgical Interventions Required for Hemorrhage Control Because the abdomen is already open during a cesarean section, step-wise surgical devascularization and compression sutures were utilized almost exclusively in the CS group. Crucially, the need for life-saving obstetric hysterectomy was significantly higher post-cesarean.

Table 5: Severe Maternal Morbidity and Mortality Outcomes Overall morbidity was higher in the cesarean cohort, largely driven by surgical complexity and morbidly adherent placentation, leading to a significantly higher rate of ICU admissions.

The findings from this one-year observational study at MKCG MCH underscore the evolving landscape of obstetric hemorrhage. Out of the 126 patients, while vaginal deliveries accounted for the absolute majority of PPH cases, the proportional severity and surgical complexity were markedly higher in the cesarean group.

Consistent with global literature, uterine atony was the undisputed leading cause of PPH (71.4%). However, the stark statistical significance of tissue-related causes (retained placenta, morbidly adherent placenta) in the cesarean group (p=0.002) highlights a modern obstetric dilemma: rising initial cesarean rates directly fuel subsequent abnormal placentation.

When evaluating risk factors, prolonged labor was strongly tied to vaginal PPH (p=0.04), often a consequence of delayed referrals from peripheral centers in Odisha. Conversely, placenta previa and accreta spectrum disorders were the primary catalysts for severe hemorrhage in cesareans (p=0.001). This heavily influenced intervention strategies. Surgical steps like B-Lynch sutures and vessel ligations were extensively utilized in the cesarean cohort, logically due to open abdominal access. However, the significantly higher rate of peripartum hysterectomies in the CS group (11.5% vs 2.7%, p=0.04) reflects the intractable nature of bleeding caused by placental invasion compared to simple atony.

Maternal outcomes mirrored these clinical challenges. Intensive Care Unit admissions were significantly elevated in the cesarean cohort (23.0% vs 10.8%, p=0.04). Fortunately, despite high rates of hemorrhagic shock, the absolute mortality remained low (3 cases total), reflecting aggressive blood bank support and timely surgical decisions at the study institution.

Postpartum hemorrhage remains a formidable challenge at tertiary referral centers like MKCG MCH. While uterine atony is the most common etiology across the board, the nature of PPH following cesarean sections is distinctly more aggressive, driven by placental anomalies and requiring complex, life-altering surgical interventions like obstetric hysterectomy. Combating this requires a dual approach: robust intrapartum monitoring to prevent prolonged labor in vaginal deliveries, and stringent justification for primary cesareans to curb the rising tide of placenta accreta spectrum disorders.

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