Pregnancy ends with labour and then the child is born. Labour is divided in three phases - dilation of the cervix, birth of the baby and expelling the placenta. The third stage of labour is the most dangerous phase of childbirth due to risk of postpartum hemorrhage. Postpartum haemorrhage ( PPH) refers to more than 500 ml of blood loss after vaginal delivery or more than 1000 ml after caesarean delivery in the first 24 hours after childbirth.

As per World Health Organisation estimates, around 70,000 women die every year due to postpartum haemorrhage. This condition affects every 1 in 10 women in Europe and 67000 women in the UK every year during childbirth. It is very common in low and middle income countries and it is the leading cause of maternal deaths all around the world. 

Heavy blood loss can happen from various parts of the body such as the cervix, vagina, uterus or perineum so it can be classified as placental bleeding or extra-placental bleeding. Postpartum bleeding is normal for up to 6 weeks post childbirth. 

There are two types of postpartum haemorrhage:¹

• Primary postpartum haemorrhage: heavy blood loss in the first 24 hours after childbirth 
• Secondary postpartum haemorrhage: heavy blood loss 24 hours - 12 weeks after childbirth  

Significance of addressing postpartum haemorrhage

Postpartum bleeding in the first 24 hours should be carefully monitored to keep the situation under control. It can turn dangerous, but it is manageable if detected early. Detecting it on time is the biggest challenge and can be life-saving. Healthcare providers assess the bleeding visually which can be underestimated at times. If it is diagnosed on time, treatment can start in a sequential manner.

Causes of postpartum haemorrhage

Childbirth is usually followed by bleeding as the body tries to expel the placenta out. Postpartum haemorrhage can be due to various reasons.²^,³

Primary postpartum haemorrhage occurs due to the following reasons.

• Uterine atony: uterine atony accounts for around 70% of the cases. Soft uterus which lacks muscle tone won't be able to contract properly during or after childbirth. This can cause the blood vessels to bleed freely causing postpartum hemorrhage 
• Retained placenta: retained placenta is caused when the placenta is not expelled out after 30 minutes of childbirth automatically. It can be due to uterine atony. It happens in around 10% of the cases. An injection can be administered for expelling the placenta 
• Uterine inversion: uterine inversion or inverted uterus is a rare childbirth complication where the uterus turns inside out partially or completely. This can cause severe blood loss, shock or death and needs to be treated immediately 
• Coagulation disorders: also called blood clotting disorders or thrombophilias. Our body has a mechanism to prevent excessive bleeding by formation of blood clots after an injury. In this condition, the body may form clots without injury or may not form clots leading to excessive bleeding
• Genital tract lacerations: also called perineal lacerations. It is a tear in the tissue surrounding vagina and perineum. Around 90% of pregnant women experience some form of vaginal tear 

Secondary postpartum haemorrhage occurs due to the following reasons.

• Infection: an infection due to remaining placental tissue can lead to postpartum haemorrhage
• Retained conception products
• Placental site

Risk factors for postpartum haemorrhage

Postpartum haemorrhage needs quick intervention to prevent any life-threatening situation. Some of the common risk factors associated with it are:²^,³^,⁴

• Vaginal lacerations
• Retained placental tissue
• Prior uterine surgery or caesarean section
• Coagulation disorders
• Multiple gestation
• Hypertension
• General anaesthesia
• Prolonged use of oxytocin
• Short umbilical cord

Signs and symptoms of postpartum haemorrhage

Postpartum haemorrhage can be identified by the following signs and symptoms.²

• Uncontrolled bleeding
• Increased heart rate
• Pain and swelling in the genital area
• Reduced blood pressure
• Reduced levels of red blood cells
• Feeling dizzy
• Feeling cold
• Increased respiratory rate

Diagnosis of postpartum haemorrhage

Diagnosis of postpartum haemorrhage can be done in the following ways.²

• Vitals: measuring vitals such as heart rate and blood pressure is important in recognising the haemorrhage and dealing with it in timely manner
• Blood loss: blood loss should be carefully estimated
• Blood cells count: complete blood count should be done to assess the level of blood cells in the body
• Ultrasound: ultrasound must be performed to check for any retained placental tissue
• Physical assessment: a physical examination must be performed to check for any vaginal tears, uterine rupture or hematomas

Treatment of postpartum haemorrhage

If postpartum haemorrhage is diagnosed, it should be treated without delay. Treatment can depend on the severity and cause of haemorrhage.²^,5

• Medications: if uterine atony is causing postpartum hemorrhage, then medications known as uterotonics should be administered. These drugs increase the tone and contractions of the uterus. Oxytocin is the preferred drug in most cases. Other uterotonics are ergometrine, misoprostol, cabetocin
• Uterine tamponade: an intrauterine balloon filled with 250-500 ml normal saline can be placed to control the bleeding. It is important to remember to take it out after a set time
• Laparotomy: this is considered when other options have failed. A midline vertical incision on the abdomen is done for normal delivery patients. If the patient had undergone caesarean section, that incision can be used. Uterine atony can be managed with uterine compression sutures
• Hysterectomy: this is the last resort for treating haemorrhage.  Peripartum or supracervical hysterectomy may be performed depending on the patient's condition. Peripartum hysterectomy is associated with increased risk of bladder and urethral injury along with permanent sterility. While, supra cervical hysterectomy comparatively poses less risks

Prevention of postpartum haemorrhage

If healthcare providers assess the risk and take preventive measures, then there are chances that hemorrhage won't turn life-threatening. According to the WHO recommendations, all women should be given uterotonic drugs in the third stage of labour to prevent any chances of postpartum hemorrhage. 

Complications 

Postpartum hemorrhage causes excessive bleeding which can cause shock or death if not treated in a timely manner. Losing a lot of blood might make you anaemic and feel more tired.

FAQs

Who is at higher risk of postpartum haemorrhage?

Patients who have had multiple children, experienced postpartum haemorrhage in previous pregnancies, vaginal laceration, prior uterine or caesarean surgery, coagulation disorders, hypertension and/or prolonged use of oxytocin are at higher risk of postpartum haemorrhage.

How long after birth can postpartum haemorrhage happen?

Primary postpartum haemorrhage happens between childbirth to 24 hours after childbirth. Secondary postpartum haemorrhage happens between 24 hours to 12 weeks after childbirth.

Is haemorrhage more likely after a C-section?

Yes. Haemorrhage is more likely to happen after C-section.

How serious is postpartum haemorrhage?

Postpartum haemorrhage can turn fatal if not treated on time. 

Summary 

Blood loss of more than 500 ml is postpartum haemorrhage. It occurs in the third stage of labour which is the phase between the birth of the child to expulsion of the placenta. This phase carries a risk of postpartum haemorrhage which makes it a dangerous phase. Haemorrhage in the first 24 hours after childbirth is primary. Whereas, haemorrhage occurring between 24 hours to 12 weeks after childbirth is secondary. If the situation is not identified and treated on time, it could turn life-threatening. WHO recommends giving uterotonic drugs which help in contracting the uterine muscles during birth to prevent the chances of postpartum haemorrhage. This helps in preventing excessive bleeding. Treating postpartum haemorrhage costs the NHS around 32-180 million pounds every year. Depending on the severity of the symptoms, around 488-2700 pounds is spent on treating every patient affected by postpartum haemorrhage in the UK. 

Postpartum haemorrhage can be identified by uncontrolled bleeding, increased heart rate and respiratory rate, reduced blood pressure, pain and swelling in the genital area, feeling cold and dizzy. It can be diagnosed by measuring vitals, blood counts, ultrasound and physical assessments. 

Primary haemorrhage can be caused due to uterine atony, retained placenta, uterine inversion, coagulation disorders or genital tract lacerations. Secondary haemorrhage can be caused due to infections or retained conception products. Haemorrhage can be treated by uterine tamponade, uterotonics, laparotomy or hysterectomy.