Haemorrhage continues to be the most significant direct cause of maternal death, accounting for 661 000 deaths worldwide between 2003 and 2009. Most of these deaths occur during the immediate postpartum period and are due to uterine atony, a condition characterised by the failure of the uterus to contract adequately after the delivery of the placenta.
Most women with postpartum haemorrhage (PPH) respond well to first-line interventions (uterotonics, uterine massage, tranexamic acid). However, 10–20% are unresponsive to these interventions – a subgroup (denoted as ‘refractory PPH’) where most of the PPH-related morbidity and mortality are concentrated. Between one-third and one-half of refractory PPH cases are due to uterine atony. Laparotomy for compressive sutures, ligation of uterine blood supply or hysterectomy is frequently needed to prevent deaths among these women. Embolisation of uterine arteries by interventional radiology is also an option, although availability in low-resource settings is very limited.