Introduction

Pregnancy can be physiologically stressful, due to the array of changes that occur to the woman’s body antenatally and during childbirth. These changes are primarily physical and affect the different body systems. The maternity period can come with many challenges and complications, one being postpartum haemorrhage (PPH) which requires prompt recognition and early treatment. Nonetheless, measures to prevent PPH are one of the main goals of risk assessment. 

A haemorrhage is described as blood loss from a damaged blood vessel. Depending on the quantity of blood lost, it can be classified as a minor or major bleed.

Postpartum Haemorrhage is defined as heavy bleeding from the vagina following childbirth and occurs anytime immediately after delivery, and up to twelve (12) weeks after birth. It is a rare complication and does not affect the majority of women. After normal vaginal delivery, bleeding up to 500 mls is normal, but any more than this, especially over 1000 mls of blood, then it becomes worrisome.

PPH can be classified as primary or secondary postpartum haemorrhage. Most cases require immediate management through simple procedures while others may require more serious measures.

Overview

According to the Royal College of Obstetrics and Gynaecology, Postpartum haemorrhage is a total blood loss of more than 500mls with signs and symptoms of reduced blood volume within 24 hours after birth.¹ Minor PPH consists of a loss of blood of between 500-1000 MLS, while major PPH consists of blood loss of 1000mls or more. It can occur after both vaginal delivery and delivery through a caesarean section. ‘

Signs and symptoms of reduced blood volume may occur, including dizziness, feeling faint, nausea and potentially loss of consciousness. Although post-partum haemorrhage is rare, it is the primary cause of death in women post-delivery worldwide and ranked third in the UK.² Per vagina, bleeding of less than 500 MLS, after delivery of the baby is usually normal as the source of this bleeding comes from where the placenta was implanted in the uterus (womb). However, the most common cause of PPH is the uterus being unable to relax on its own after delivery, causing blood loss and this is attributed to 70-80% of cases.³ Other causes of postpartum bleeding may be due to instrumental injuries caused by using operative instruments during delivery, tears, infections of the genital tract, or remnants of the placenta in the uterus.

Post-partum haemorrhage can be differentiated by timing, amount of blood lost and causes.

Timing:

• Primary Postpartum Haemorrhage: Loss of 500 mls of blood or more per vagina within 24 hours post-delivery. 
• Secondary postpartum Haemorrhage: excessive bleeding that occurs per vagina after 24 hours and up to twelve (12) weeks after delivery.

 Amount of blood loss:

• Minor: Blood loss between 500 mls and 1000 mls. 
• Major: Blood loss of more than 1000 mls.¹

Causes

• Tone (no relaxation): This results from the womb not contracting normally and is due to the uterus over-expanding, a full bladder, or multiple pregnancies.
• Trauma (tears or injuries): As a result of a cut made to the vagina to allow easy passage of the baby. Also, instruments may be used to help bring the baby out and these could cause tears in the uterus.
• Tissue (retained products or tissue): Sometimes, the placenta may not be completely removed, and the remnants will cause bleeding.
• Thrombin (blood clotting): In conditions with blood clotting problems or conditions related to pregnancy like eclampsia that affects blood clotting abilities of the blood, they can result in uncontrollable bleeding.⁶

Treatment approaches

Postpartum haemorrhage is regarded as an emergency and there are existing guidelines outlining how to handle the condition depending on the situation after a home birth or in the hospital.

At first, the midwife should call for help.¹ A group of expert health professionals will manage the situation and are expected to keep the patient and partner informed throughout.  The healthcare professionals must constantly monitor the blood pressure and pulse (heartbeat) which will indicate whether the situation is worsening. Further steps the midwife may carry out include.

• The midwife will massage the womb at the topmost part called the fundus, this is referred to as uterine massage and stimulates the vagina to contract
• An injection is given through the thigh called oxytocin, or a prostaglandin called misoprostol inserted into the vagina will also stimulate your womb to contract ⁴
• A catheter, which is a tube placed in the bladder and used to collect urine, is recommended to be inserted. This is because the bladder is closely located to the uterus and a full bladder may prevent the uterus from contracting.
• Blood samples are taken, and fluids will be initiated through the vein to keep the circulation going.
• The midwife or doctor may then go ahead to check the uterus through the vagina to ensure that all the parts of the placenta have been expelled. If the placenta has not fully been expelled, the healthcare professional will have to remove the placenta manually in the theatre. Injections will be administered to numb the pain.  Healthcare professionals will also check for any injuries or tears that could be the source of the bleeding.  If any sources of bleeding are found, they will be repaired with stitches.

What if the bleeding continues? 

• The medication will be repeated to stop the bleeding.
• Oxygen will be administered via a facemask, and fluids will run through another intravenous line.
• If blood levels continue to fall, the doctors may decide to give blood instead of fluids to help with blood circulation or a medication that can help make the blood clot.
• If the bleeding does not stop, you will be moved into the theatre for the doctors to identify the source of the bleeding.  And you will receive a drug to numb the pain or put you to sleep.¹

The following steps will be taken in the theatre:  

• A process called “balloon tamponade” in which a balloon is used to apply pressure on the bleeding blood vessels.  This will be placed into the uterus and inflated. It is removed a day after the bleeding stops.
• Surgery may need to be performed to help identify the source of bleeding.
• In very severe cases and rarely, the woman’s womb may be removed in a procedure called hysterectomy.
• Occasionally, a specialist-trained radiologist may need to perform a  “uterine artery embolisation” to stop the bleeding. This is achieved by using a small catheter to inject tiny particles into the vessels that supply blood to the uterus with the help of an X-ray for visualisation to block them.
• In the case of an infection, you will be given antibiotics orally or through the vein. The symptoms to look out for are smelling lochia, a fever or generally feeling unwell.

When bleeding is controlled, you may be taken to the labour ward or the intensive care unit for continuous monitoring, depending on your condition.

Prevention strategies

• During the pregnancy, the doctors will regularly check blood levels for increased risks of PPH ⁵.
• If blood levels are lower than the normal range in pregnancy, you will be started on medication or require a blood transfusion.⁶
• Immediately after delivery of the newborn, the midwife will routinely administer a medication which will help the uterus to contract.
• If there is a higher risk of PPH and delivery is through caesarean section, it is recommended that an additional drug is given to help the blood clot.

Summary

Bleeding after childbirth is normal and this is referred to as lochia. The quantity reduces over time but can last for weeks, changing from bright red to dark red blood.  

Registering for antenatal care during pregnancy is necessary as this will help reduce the chances of complications. If you are considered at risk of PPH, the midwife or doctor will advise you to deliver in a hospital. PPH occurs when you bleed heavier than normal and can present with symptoms and signs, it does not happen to every woman. 

It can be managed effectively in a hospital by certain procedures, but it may become difficult resulting in more complex procedures. Many hospitals have set guidelines for the management of  PPH as recommended by RCOG. If you are unsure of your care or risks, please ask for advice from your healthcare provider.

FAQs

How do I know if I am at risk of PPH?

There are many risk factors for PPH.  It ranges from multiple pregnancies, PPH in previous pregnancies, and big babies. The risk increases with multiple pregnancies, older age at childbirth and infections of the vagina. Your midwife or doctor will assess you for the risk and be prepared for the possibility. 

Conditions that lead to increased blood clotting or other health conditions may also be a predisposing factor. If you are worried about your risk, you can speak to your midwife or doctor about it.

Is it a common complication?

PPH is a rare complication of pregnancy, but it is the most common cause of death in women after delivery.

Is there anything I must do to prevent it?

There is nothing you can do to prevent the risk. You should attend all your regular checkups during the antenatal period this would help the midwife and doctor determine any potential complications early on in the pregnancy. 

Are there any long-term consequences if I experience postpartum haemorrhage?

There are many consequences of PPH. These include reduced blood volume resulting in reduced blood pressure, pulse rate and subsequently reduced blood flow to important organs in the body. The organs may try to compensate for a while but if PPH is not handled immediately, the organs may fail. There is also an increased risk of infection during the post-partum period and the formation of blood clots in the vein which can travel and cause damage. Another consequence is long hospital stays as you will have to be admitted for a longer period for observation.

Can I have PPH again in another pregnancy?

Yes, the risk of having PPH in another pregnancy is higher.