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Daytime Compared With Nighttime Differences in Management and Outcomes of Postpartum Hemorrhage

Yee, Lynn M., MD, MPH; McGee, Paula, MS; Bailit, Jennifer L., MD, MPH; Reddy, Uma M., MD, MPH; Wapner, Ronald J., MD; Varner, Michael W., MD; Thorp, John M. Jr, MD; Leveno, Kenneth J., MD; Caritis, Steve N., MD; Prasad, Mona, DO, MPH; Tita, Alan T. N., MD, PhD; Saade, George, MD; Sorokin, Yoram, MD; Rouse, Dwight J., MD; Blackwell, Sean C., MD; Tolosa, Jorge E., MD, MSCE; ; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network

doi: 10.1097/AOG.0000000000003033
Contents: Quality of Care: Original Research

OBJECTIVE: To assess whether postpartum hemorrhage management or subsequent morbidity differs based on whether delivery occurred during the day or night.

METHODS: We conducted a secondary analysis of a multicenter observational obstetric cohort of more than 115,000 mother–neonate pairs from 25 hospitals (2008–2011). This analysis included women delivering singleton or twin births who experienced postpartum hemorrhage (estimated blood loss greater than 500 cc for vaginal delivery, estimated blood loss greater than 1,000 cc for cesarean delivery, or documented treatment for postpartum hemorrhage). Nighttime delivery was defined as that occurring between 8 pm and 6 am. The primary outcome was a composite of maternal morbidity (death, hysterectomy, intensive care unit admission, transfusion, or unanticipated procedure for bleeding). Secondary outcomes included estimated blood loss, uterotonic use, and procedures to treat bleeding that occurred during the postpartum hospitalization. Multivariable logistic, linear, quantile, and multinomial regression models were used to assess associations between nighttime delivery and outcomes, adjusting for potential patient-level confounders and hospital as a fixed effect.

RESULTS: In total, 2,709 (34.2%) of 7,917 women with postpartum hemorrhage delivered at night. Women who delivered at night were younger, had a lower body mass index, and were more likely to have government-sponsored insurance, be nulliparous, have hypertension, use neuraxial analgesia, and deliver vaginally. After adjusting for potential confounders, the primary composite outcome of maternal morbidity was similar regardless of night compared with day delivery (15.5% night vs 17.5% day; adjusted odds ratio 0.89, 95% CI 0.77–1.03). Some secondary outcomes, including mean EBL, frequency of uterotonic use, and time from delivery to first uterotonic dose, differed on unadjusted analyses, but these associations did not persist in multivariable analysis. The study had limited power to assess differences in uncommon outcomes.

CONCLUSION: Nighttime delivery was not associated with significant differences in postpartum hemorrhage–related management or morbidity.

In academic medical centers, delivery at night is not associated with differences in postpartum hemorrhage–related management or morbidity compared with delivery during the day.

Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, MetroHealth Medical Center–Case Western Reserve University, Cleveland, Ohio, Columbia University, New York, New York, the University of Utah Health Sciences Center, Salt Lake City, Utah, the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, the University of Texas Southwestern Medical Center, Dallas, Texas, the University of Pittsburgh, Pittsburgh, Pennsylvania, The Ohio State University, Columbus, Ohio, the University of Alabama at Birmingham, Birmingham, Alabama, the University of Texas Medical Branch, Galveston, Texas, Wayne State University, Detroit, Michigan, Brown University, Providence, Rhode Island, the University of Texas Health Science Center at Houston, McGovern Medical School–Children's Memorial Hermann Hospital, Houston, Texas, and Oregon Health & Science University, Portland, Oregon; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Corresponding author: Lynn M. Yee, MD, MPH, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E Superior Street, #5-2149, Chicago, IL 60611; email:

Supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (HD21410, HD27869, HD27915, HD27917, HD34116, HD34208, HD36801, HD40500, HD40512, HD40544, HD40545, HD40560, HD40485, HD53097, HD53118) and the National Center for Research Resources (UL1 RR024989; 5UL1 RR025764). Comments and views of the authors do not necessarily represent views of the National Institutes of Health.

Financial Disclosure Ronald J. Wapner serves as Principal Investigator for several studies for which CUMC receives grants. Current funding from commercial entities includes support from Natera, Inc, Sequenom, and Illumino, Inc. All funds go directly to CUMC. Dr. Wapner does not receive compensation from any of these grants. The other authors did not report any potential conflicts of interest.

Presented as a poster at the 2018 Society for Maternal-Fetal Medicine’s 38th Annual Meeting, January 29–February 3, 2018, Dallas, Texas.

*See Appendix 1, available online at, for a list of other members of the NICHD MFMU Network.

The authors thank Cynthia Milluzzi, RN, and Joan Moss, RNC, MSN, for protocol development and coordination between clinical research centers; and William A. Grobman, MD, MBA, Elizabeth Thom, PhD, Madeline M. Rice, PhD, Brian M. Mercer, MD, and Catherine Y. Spong, MD, for protocol development and oversight.

Dr. Rouse, Associate Editor (Obstetrics) of Obstetrics & Gynecology, was not involved in the review or decision to publish this article.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

© 2018 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.