Bleeding from the Lower Genital Tract

In the first comprehensive English Language textbook on the subject, William Smellie, in his 1752 Treatise on the Theory and Practise of Midwifery1, correctly identifies the atonic uterus as a major cause of postpartum hemorrhage with his statement ‘This dangerous efflux is occasioned by every thing that hinders the emptied uterus from contracting’. Although he refers to vaginal packing with Tow or linen rags (dipped in astringents such as oxycrate, red tart wine, alum or Saccharsaturni), he does not specifically refer to bleeding from the lower genital tract. Because this omission was repeated in subsequent years by many standard textbooks and reviews of postpartum hemorrhage, it is not surprising that the present evidence base is poor, and a 2005 MESH search in PubMed of the National Library USA combining the terms ‘Postpartum hemorrhage’ AND ‘Lacerations’ OR ‘Rupture’ NOT ‘Uterine rupture’ came up with only 28 publications. Maternal deaths specifically from lower genital tract bleeding as the cause of postpartum hemorrhage are rare in the developed world. The 2000–2002 United Kingdom Confidential Enquiries2 reported only one death from this cause. World-wide, no accurate figures exist, but it is likely that the numbers are significant, particularly where there is significant co-morbidity and a poorly resourced maternity infrastructure3.