It is normal to bleed after having a baby, but some women experience bleeding that is heavier than normal. This is sometimes called a postpartum haemorrhage(PPH). A major haemorrhage can be life-threatening so it is important to prevent it if possible. If it occurs it should be managed immediately with appropriate medications to prevent serious complications. In many countries, postpartum haemorrhage is a leading cause of maternal death.
Bleeding after childbirth
It is normal to bleed after having a baby. The bleeding mainly comes from the area in uterus (womb), where the placenta (afterbirth) was attached, but it can also come from any tears caused (or cuts performed) during the birth. Bleeding is usually heaviest just after birth and gradually becomes less over the next few hours. The bleeding will continue to reduce over the next few days. The colour will change from fresh red to brown over a few weeks. This bleeding is called lochia and should stop by the time your baby is 6 weeks old.
What is postpartum haemorrhage?
Postpartum haemorrhage (PPH) is often defined as the loss of more than 500 ml of blood (vaginal delivery, 1000ml for C-Section) within the first 24 hours following childbirth (Primary PPH). The condition can occur up to six weeks following delivery when it is termed secondary PPH.
What causes PPH?
Uterine atony is the most important cause of PPH and usually occurs immediately following delivery of the baby, up to 4 hours after the delivery.
Uterine atony is a failure of the uterine myometrial fibers to contract and retract.
Trauma to the genital tract (uterus, uterine cervix, vagina, labia, clitoris) in pregnancy results in significantly more bleeding than would occur in the nonpregnant state because of increased blood supply to these tissues. The trauma specifically related to the delivery of the baby, either vaginally in a spontaneous or assisted manner or by caesarean delivery, can also be substantial and can lead to significant disruption of soft tissue and tearing of blood vessels.
Risk factors for PPH?
There are several factors that increase a woman’s chances of experiencing a PPH, but it should be noted that a PPH can occur in the absence of any of these risk factors.
A woman’s risk of excessive bleeding after delivery will be assessed before the birth. If the risk is thought to be high, the woman will be advised what to do.
The risk factors before delivery include:
• Previous retained placenta or postpartum haemorrhage
• Low maternal haemoglobin level at the start of labour
• Increased body mass index (obesity)
• Four or more previous babies
• Low-lying placenta (afterbirth)
• Being 35 years or older
Risk factors in labour include:
• Induced birth
• Prolonged labour
• Rapid labour (precipitate labour)
• Operative birth
Prevention
There is clinical evidence that suggests that active management of the third stage of labour reduces the incidence and severity of PPH. Active management is the combination of (1) uterotonic administration (preferably oxytocin) immediately upon delivery of the baby, (2) early cord clamping and cutting, and (3) gentle cord traction with uterine countertraction when the uterus is well contracted.
If you have had a previous birth that was complicated by a primary PPH, there is an increased risk of PPH in future pregnancies – 1 in 10 women will have a PPH again in a future pregnancy. It is therefore important that you inform your obstetrician about this so that appropriate measures can be taken.
How do you know you are bleeding too much?
Women are often instructed what to look for to detect a PPH. If PPH occurs in hospital it is easy to diagnose. If the woman has left hospital she should contact her midwife or obstetrician if she experiences the following:
• Have bleeding that soaks through her usual pad each hour for 2 or more hours.
• Have bloody discharge that continues beyond 4 to 6 weeks.
• Pass blood clots larger than a cricket ball over several hours.
Do not be concerned if you pass occasional blood clots, as long as they are smaller than a cricket ball.
Postpartum haemorrhage treatment
Immediate treatment will be given for individuals experiencing a postpartum haemorrhage. This is usually led by an experienced obstetrician and midwife. Treatment includes:
• Uterine massage
• IV fluids (drip)
• Oxytocin (which makes the muscles of the uterus contract to reduce bleeding) and other drugs.
If blood loss is very severe, a blood transfusion may be necessary. In some circumstances surgery might be indicated. In a few cases a hysterectomy may be required.
Prognosis
The prognosis depends on the cause of the PPH, its duration, the amount of blood loss, comorbid conditions, and the effectiveness of treatment. Prompt diagnosis and treatment are essential to achieving the best outcome for any given patient. Most women will do well if managed promptly. In a few cases, death might occur despite all the advances in medicine. Postpartum hemorrhage is a potentially life-threatening complication of both vaginal and cesarean delivery. Associated morbidity is related to the direct consequences of blood loss as well as the potential complications of hemostatic and resuscitative interventions.
Conclusion
Postpartum haemorrhage is a serious medical emergency that, if not managed urgently and professionally, can result in serious complications. Efforts at preventing this disorder is very important. Patients and healthcare providers must be always looking out for this potentially life-threatening condition.
Ask Your Doctor is a health education column and is not a substitute for medical advice from your physician. The reader should consult his or her physician for specific information concerning specific medical conditions. While all reasonable efforts have been made to ensure that all information presented is accurate, as research and development in the medical field are ongoing, it is possible that new findings may supersede some data presented.
Dr Brett Hodge MB BS DGO MRCOG, is an Obstetrician/Gynaecologist and Family Doctor who has over thirty-two years in clinical practice. Dr Hodge has a medical practice in The Johnson Building in The Valley (Tel: 264 4975828).
