**1. Introduction**

Hemorrhage is the cause of 12.0–18.0% of deaths during pregnancy [1–3]. Severe postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity [4, 5] and is increasing in incidence worldwide [6, 7], especially in low resource countries [8]. Emergency hysterectomy is increasingly performed to treat uncontrollable PPH [1–3]. It was performed at the time of, or within 24 h of, a vaginal or abdominal delivery for the treatment of hemorrhage that was unresponsive to unservative approaches [9]. Variability in the incidence of PPH-related hysterectomy is different in various countries and even among institutions [9–13].

According to recent reports, 0.20–5.09 of every 1000 postnatal women across the globe have undergone an emergency hysterectomy [14]. Hysterectomy is considered to be a safe, low-risk surgery. It is, by nature, unplanned and performed expeditiously in the case of severe PPH. It may not be the best option for all women, especially those who still want to have children. Some people may have an adverse reaction to the anesthetic, heavy bleeding, and infection around the incision site [15].

The guidelines of the World Health Organization (WHO) aim to prevent and manage PPH by active management of the third stage of labor (AMTSL) [16]. Thai government policy to prevent PPH in 2013 was involved in the project—Every Woman Every Child (EWEC) to decrease maternal mortality and child mortality by 16 million cases in 2015 [17, 18]. However, the incidence of PPH was increased from 2.30 to 2.65% from 2009 to 2015 [19]. In low-resource city with various ethnic groups, surrounded by mountains and forests as in Chiang Rai province and Sakon Nakhon province [20, 21]. The incidence of PPH is increasing in Chiang Rai from 1.12 to 2.07%, but maternal death from PPH decreased from 3.05 to 1.23% during 2012-2015 [20]. In the fiscal year 2014–2015, PPH-related hysterectomy decreased in number from 2 cases to 1 case [20]. In Sakon Nakhon, during 2015–2018 the incidence of PPH is about 1.13–1.39%. The maternal deaths were decreased from 33.83 to 27.84 per 100,000 infant live births. However, it was higher than the standard criterion of 17.0 per 100,000 infant live births [21].

A tool developed from significantly high-risk factors [22–24] associated with PPH was performed in western societies and Thailand [25–29]. These tools can detect PPH earlier and can reduce the number of maternal deaths and PPH-related hysterectomies in Thailand [20, 21].

This study aimed to synthesize knowledge about the early management of PPH, summarize the appropriate risk score tool for the prediction of PPH, and reduce the number of maternal deaths and PPH-related hysterectomy cases in two lower resource cities in the north and northeast of Thailand.

## **2. Objectives**

The objective of this study was to synthesize knowledge about the early management of PPH and an appropriate risk score tool to reduce PPH-related hysterectomy cases in two lower resource cities in the north and northeast of Thailand.
