Recognizing and Managing Postpartum Hemorrhage: Key Information for Safe Recovery

Postpartum hemorrhage (PPH) is a serious and potentially life-threatening condition characterized by excessive bleeding following childbirth. It is defined as a blood loss of more than 500 milliliters after vaginal delivery or more than 1,000 milliliters after a cesarean section. PPH can occur within the first 24 hours after birth (primary PPH) or more than 24 hours but within 12 weeks (secondary PPH). It is important to be aware of the symptoms of PPH, know the risk factors, and seek medical attention immediately if you suspect you are experiencing PPH. Please keep reading for details on the following topics:

Causes of PPH

Risk factors for PPH

Management of PPH

A heavily soaked sanitary pad and mackintosh, displaying blood and clots.

CAUSES OF POSTPARTUM HEMORRHAGE

  • Uterine Atony: The womb not properly contracted. This is the most common cause of PPH and occurs when the uterus fails to contract after delivery. Normally, the uterus contracts to constrict blood vessels and stop bleeding after the placenta is delivered.
  • Retained Placenta: If parts of the placenta remain in the uterus (womb) after delivery, it can lead to bleeding. This is a common cause of secondary PPH.
  • Genital Tract Lacerations: Tears in the cervix, vagina, or perineum during childbirth can cause bleeding.
  • Placenta Previa or Placental Abruption: Conditions where the placenta is abnormally positioned or detaches prematurely from the uterine wall can result in significant bleeding during delivery.
  • Coagulation Disorders: If the mother has a clotting disorder (e.g., thrombocytopenia or disseminated intravascular coagulation), it can prevent proper clot formation and result in excessive bleeding.
  • Uterine Rupture: This is a rare but serious cause where the uterus tears during labor, often during a trial of labor after a cesarean section (TOLAC).

RISK FACTORS FOR POSTPARTUM HEMORRHAGE (PPH)

  1. Had Heavy Bleeding After Delivery in a Previous Pregnancy (History of PPH):
  • If a woman has had PPH in a previous pregnancy, she is at a higher risk of experiencing it again in subsequent pregnancies. This is especially true if the cause of the previous PPH was not fully addressed or if the woman has other risk factors.

2. Uterine Inversion:

  • Uterine inversion occurs when the uterus turns inside out during delivery, typically after the placenta is delivered. This is a rare but serious complication that can cause severe bleeding. It usually requires immediate intervention to restore the uterus to its normal position.

3. Uterine Rupture:

  • Uterine rupture happens when the wall of the uterus tears during labor, which can lead to rapid and severe bleeding. It is more likely in women with previous cesarean sections or uterine surgeries. It’s a life-threatening complication that requires immediate surgical intervention.

4. Excess Amniotic Fluid (Polyhydramnios):

  • Polyhydramnios is a condition where there is too much amniotic fluid around the baby during pregnancy. This can lead to a more stretched and overdistended uterus, which can increase the risk of uterine atony (failure of the uterus to contract properly) and postpartum hemorrhage.

5. Placenta Previa or Placental Abruption:

  • Placenta previa occurs when the placenta is located low in the uterus and covers the cervix. This can cause bleeding during pregnancy and delivery and may result in hemorrhage after childbirth if not managed properly.
  • Placental abruption happens when the placenta prematurely detaches from the uterine wall, leading to heavy bleeding during labor and an increased risk of postpartum hemorrhage.

6. Unrepaired Vaginal or Cervical Tears:

  • If tears occur during delivery (especially with a forceps or vacuum-assisted delivery) and are not properly repaired, they can continue to bleed, contributing to postpartum hemorrhage.

7. Taking Drugs or Herbs that Interfere with Blood Clotting:

  • Aspirin, ibuprofen, ginkgo biloba, and large doses of vitamin E can interfere with blood clotting and increase the risk of excessive bleeding during and after delivery. Women who are taking these substances need to inform their healthcare providers before delivery.

8. Ingestion of Spices (Turmeric, Cinnamon, Bay Leaf, Garlic):

  • While these spices have health benefits, they can also have anticoagulant (blood-thinning) properties when consumed in large amounts. This can potentially interfere with the body’s ability to form blood clots, leading to an increased risk of bleeding.

9. Prolonged Labor or a Fast Delivery:

  • Prolonged labor can cause fatigue and lead to uterine atony due to overuse of the uterine muscles, increasing the risk of hemorrhage. On the other hand, fast deliveries can cause trauma to the birth canal, resulting in tears or lacerations that contribute to bleeding.

10. Use of Forceps or Vacuum Extraction:

  • The use of forceps or vacuum extraction during delivery can increase the risk of tears in the cervix or vaginal walls, leading to postpartum hemorrhage. These instruments are typically used when there are complications with the delivery process.

11. Multiple Pregnancies (Twins, Triplets, etc.):

  • Multiple pregnancies increase the likelihood of overdistension of the uterus, which can impair uterine contractions after delivery, leading to uterine atony. The increased size of the uterus also raises the risk of complications such as retained placenta or tears.

12. High Parity (Having Many Children):

  • Women who have had many children (i.e., have high parity) are at greater risk of uterine atony and other complications during childbirth. The uterus may become less efficient at contracting after multiple pregnancies, increasing the risk of PPH.

13. A History of PPH in Previous Pregnancies:

  • A history of postpartum hemorrhage makes it more likely that a woman will experience it again. This is particularly true if the underlying cause of the bleeding was not resolved in previous pregnancies.

14. Certain Pregnancy Complications (e.g., Preeclampsia or Placenta Previa):

  • Preeclampsia (high blood pressure during pregnancy) can lead to complications such as placental abruption and uterine atony, increasing the risk of bleeding.
  • Placenta previa (as mentioned above) increases the risk of bleeding during and after delivery.

15. Cesarean Delivery or Uterine Surgery:

  • A cesarean section or any surgery on the uterus (like fibroid removal or a previous uterine rupture) can increase the risk of bleeding due to the possibility of uterine scarring, retained placenta, or complications during healing after the procedure.

16. Obesity:

    • Obesity increases the risk of postpartum hemorrhage due to several factors, including an increased likelihood of cesarean delivery, uterine atony, and difficulties in repairing vaginal tears. It may also contribute to other pregnancy complications like preeclampsia and gestational diabetes, which can increase the risk of hemorrhage.
Symptoms of Postpartum Hemorrhage:

Excessive vaginal bleeding: More than the typical amount after delivery.

Signs of shock: These can include low blood pressure, rapid heart rate, pale or clammy skin, dizziness, fainting, and confusion.

Large blood clots or a gush of blood.

Abdominal pain or swelling (especially if the cause is uterine rupture or retained placenta).

Anxiety and restlessness.

MANAGEMENT OF POSTPARTUM HEMORRHAGE

A unit of blood hanging from an IV pole, ready for transfusion.

  1. Uterine Massage: A healthcare provider may massage the uterus to help it contract and reduce bleeding. This is usually the first step in managing uterine atony.
  2. Medications:
    • Oxytocin (Pitocin) is commonly used to stimulate uterine contractions and reduce bleeding.
    • Misoprostol (Cytotec) or Carboprost may also be used if oxytocin is not effective.
    • Ergometrine (ergonovine) is a type of ergot alkaloid that acts directly on the smooth muscles of the uterus, causing them to contract and thus reduce bleeding.
  3. Manual Removal of the Placenta: If parts of the placenta remain in the uterus, a provider may need to manually remove them to stop the bleeding.
  4. Surgical Interventions:
    • Bimanual compression or other procedures may be needed if bleeding continues despite uterine massage and medications.
    • In severe cases, procedures like uterine artery embolization or even a hysterectomy (removal of the uterus) may be necessary to control the bleeding.
    • Repair of tears: If trauma or lacerations are causing bleeding, they may need to be repaired surgically.
  5. Blood Transfusion: If the mother has lost a significant amount of blood, a transfusion may be needed to stabilize her and replace lost red blood cells.
  6. Treatment of Underlying Conditions: If there is an underlying issue like a clotting disorder, appropriate treatment for that condition will be provided.
  7. Monitoring: Continuous monitoring of vital signs (heart rate, blood pressure) and blood loss is crucial. The woman may need close observation in a critical care setting depending on the severity of the hemorrhage.
Prevention of Postpartum Hemorrhage:
  • Identifying women at higher risk for PPH (e.g., those with previous PPH, multiple pregnancies, or placental complications) can help guide preventive strategies.
  • Active management of the third stage of labor: This includes giving the mother oxytocin after the baby is born to help the uterus contract, delivering the placenta carefully, and applying gentle cord traction.
  • Skilled care during labor and delivery: Ensuring that the birth is attended by healthcare professionals who can recognize and manage complications.
  • Careful management during delivery: Ensuring that the placenta is completely delivered and that any tears are promptly repaired.
  • Early detection: Monitoring blood loss during labor and immediately after birth to detect any signs of excessive bleeding.
  • Stopping the bleeding
  • Replacing the blood lost
  • Administering fluids
  • Physical examination to determine the cause
  • Administering medication to help control the bleeding
  • Catheterization the keep the bladder empty so that the womb can contract
  • Close monitoring of the vital signs
  • Surgery depending on the cause of the bleeding

Disclaimer: The information provided in this content is for general informational purposes only. It is not intended as medical or healthcare advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare professional with any questions you may have regarding a medical condition or healthcare decisions.

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