What is Postpartum Haemorrhage?
It is normal to lose some blood during delivery. Bleeding occurs from open blood vessels in the uterus (where the placenta was attached), or from a minor episiotomy tear, which is then stitched up.
But if the bleeding is more than usual, it can be really worrisome. This abnormal bleeding is called postpartum haemorrhage (PPH). It usually occurs within 24 hours (termed as early PPH), but can also occur after 24 hours post-delivery (late PPH). The average amount of blood loss is 500 ml after vaginal delivery and 1000 ml for a caesarean section.
Losing such a large amount of blood can be life threatening and requires immediate medical attention.
What are the causes of postpartum haemorrhage?
Normally, during delivery, when the placenta begins to separate, the blood vessels bleed into the uterus. After the placenta is delivered, these blood vessels are closed off by the contraction of uterus and thus the bleeding stops.
But when the uterus fails to contract after delivery of the placenta, the bleeding continues.
This inability of the uterus to contract is called ‘uterine atony’ and is the most common cause of postpartum haemorrhage.
Trauma during delivery
Trauma is termed used for any factor that causes injury to a woman’s body during delivery. Examples of such factors include:
· Cervical lacerations,
These are cuts and bruises inflicted to the cervical region.
· Deep tears in your vagina or perineum
These are deep cuts that affect the perineal region of the body.
· A large episiotomy
This is surgical procedure that is performed on a pregnant woman in order to widen the opening of the vagina and thereby facilitate easier delivery of the baby.
· Ruptured uterus
This is sudden breach of the wall of the uterus.
Retained placenta occurs when a part, or all, of the placenta remains in the uterus after delivery.The presence of the placenta prevents the uterus from contracting back to its smaller shape, and thus the blood vessels that were exposed during childbirth will continue to bleed.
Risk factors of Postpartum Haemorrhage
Pregnant women carrying pregnancy past 20 weeks are at risk of postpartum bleeding. But in most women, risk factors are not identifiable so health practitioners should monitor every woman in delivery for PPH.
Some risk factors include:
· Postpartum haemorrhage in a previous pregnancy
· Placenta previa or placenta accreta
· Multiple births
· Failure to progress during second stage of labour
· Inducing labour, particularly with oxytocins
· Delivering a large-for-gestational-age baby
· Instrumental delivery
· Hypertensive disorders
· Systemic blood clotting disorders
What are the signs and symptoms of postpartum haemorrhage?
Postpartum haemorrhage usually presents with heavy vaginal bleeding that can quickly lead to hypovolemic shock. Blood can be seen at the vagina, especially if the placenta has been delivered.
How do we manage postpartum haemorrhage?
Prompt action must be taken when managing a case of postpartum haemorrhage by decreasing the loss of blood in order to prevent the occurrence of severe hypovolemia.
Health practitioners can give uterotonic medicine, usually oxytocin or misoprostol within minutes of delivery to help the uterine contraction to start rather than waiting for the uterus to contract naturally.
Massaging the uterus to help it contract is commonly done in this case. Beginning breastfeeding soon after birth stimulates the production of oxytocin in the mother’s body, helping to cause uterine contractions and the expulsion of the placenta naturally.
In most cases, the uterotonic medication works rapidly and the uterus contracts, thus stopping the bleeding.
If the bleeding continues after this treatment, doctors will look for any source of bleeding like lacerations or retained fragments of placenta in the uterus. If needed, a procedure called dilation and curettage (D&C) may then be done to remove any retained placenta.
In case of uncontrollable or profuse bleeding, a blood transfusion will be done to stabilize the vital signs (blood pressure, pulse). Transfusions are rarely needed. Even more rarely, a hysterectomy may be required to stop the bleeding.