Some amount of blood loss is normal during the birthing process. The average blood loss during vaginal birth is a little more than that during a C-section delivery (1). However, in rare cases, excessive flow of blood could lead to hemorrhage, which requires immediate medical attention.
It is estimated that every year, around 500,000 women die due to this condition and about 1-5% of deliveries end up in postpartum hemorrhage, causing maternal morbidity and mortality (2).
MomJunction explains the causes, symptoms and the treatment and management of postpartum hemorrhage.
What Is Postpartum Hemorrhage?
Postpartum hemorrhage (PPH) is defined as a postpartum blood loss of 500ml or more in the case of vaginal birth and around 1500ml following a C-section.
PPH that usually happens in the first 24 hours after delivery is called primary postpartum hemorrhage. If the excessive vaginal bleeding continues between 24 hours and 12 weeks following the delivery, then it is termed as secondary postpartum hemorrhage (3). Primary PPH affects 5 in 100 women, and secondary PPH affects less than 2 in 100 women.
In the case of secondary PPH, if the bleeding is continuous then blood tests and scans will be done. Based on the results, you will be admitted in the hospital and given antibiotics through an IV or operation will be done to clear the uterus of any infections, blood clots, or any remains of small pieces of placenta.
If you see any abnormality in the postpartum bleeding, then it could be an indication of hemorrhage.
Gynecologist and obstetrician,
Consultant at Anugraha Nursing Home,
Primarily PPH occurs due to the inability of the uterus to contract (atony), resulting in increased bleeding from vessels at the placental site.
The potential causes could be anemia, twin pregnancy, multiple prior pregnancies, placenta previa or abruption etc. It could also be due to trauma to birthing tract and increased bleeding. Incomplete removal of placenta and poor blood clotting can also be a cause.
Patients undergoing cesarean and operative delivery like vacuum and forceps may have a higher chance of excessive bleeding. With continuous bleeding, the pulse rate increases, blood pressure falls and the patient goes into shock. It may even lead to her death.
In developing countries about 1.2% deliveries are associated with PPH and when it occurred about 3% of women died. Postpartum hemorrhage accounts for about 30% of maternal deaths.
What happens during PPH?
With continuous bleeding, the pulse rate of the patient increases, blood pressure falls and the patient goes into shock.
Initially, there might be a feeling of giddiness, tiredness, increased heart rate, and breathing rate. Later, the patient’s temperature drops and she will become restless or she may even lose consciousness.
How is the problem managed?
Manage anemia before delivery and actively manage placental expulsion with oxytocin or misoprostol for better contraction of the uterus.
What measures does a doctor take?
The initial treatment includes fluid replacement with intravenous fluids. The patients’ feet are elevated and oxygen is given.
Blood investigations to be done while monitoring her pulse rate, blood pressure and urine output, uterine massaging is done.
Initially, PPH is medically managed with drugs which cause the contraction of the uterus.
The first hour is called the golden hour and it is critical that the treatment is intense. A woman can bleed to death in 2 hours or less. If she bleeds continuously she may go into shock which may be irreversible.
What Are The Symptoms Of Postpartum Hemorrhage?
You may experience the below symptoms of postpartum hemorrhage:
- A decrease in the red blood cell count (hematocrit) (4)
- Uncontrolled bleeding
- Pain and swelling in the vaginal and perineal area due to hematoma bleeding
- Inadequate supply of oxygen to tissues due to decreased intravascular (blood) volume (
- Drop in blood pressure (≤ 85/45 (> 15% drop)), which may lead to shock or death if not treated on time
- Pale and clammy skin
- Loss of consciousness
- Increased heart rate (≥ 110)
Not every woman will encounter postpartum hemorrhage, but certain factors increase the risk.
What Are The Risk Factors Of PPH?
You are more likely to have PPH under the below circumstances (4, 3, 6):
- Maternal age >40 years
- A history of postpartum hemorrhage
- Gestational hypertension or preeclampsia
- Placental abruption, wherein the placenta detaches from the uterus
- Placenta previa, wherein the placenta covers the cervical opening
- Multiple pregnancies with more than one placenta and overdistention of the uterus
- Overdistended uterus, which is associated with excessive enlargement of the uterus as a result of too much amniotic fluid or a large baby (especially with birth weight over 4kg (8.8lb)).
- Prolonged labor
- Bacterial infections like chorioamnionitis
- General anesthesia
- Labor induction medications
- Medications to stop contractions of preterm labor
- Vacuum or forceps assisted delivery
- South Asian ethnicity
- Having a BMI more than 35 before birth
What Are The Causes Of Postpartum Hemorrhage?
The most common causes of postpartum hemorrhage include (7):
1. Tone (uterine atony): It is the loss of uterine musculature tone. The failure of uterine muscle contraction following the delivery of placenta makes the blood vessels to bleed profusely and leads to hemorrhage. The bleeding can also happen if any remains of the placenta are left inside the uterus.
2. Trauma: Birth-related traumas causing PPH include:
- Episiotomy that increases the risk of anal sphincter tears and blood loss.
- Uterine inversion, wherein the uterus turns inside out. It rarely occurs, in 0.05% of deliveries.
- Uterine rupture, which occurs in 0.6 to 0.7% of VBAC deliveries in women with an unknown uterine scar or a low traverse uterine scar.
3. Tissue: It includes two conditions of the placenta:
- Retained placenta: The placenta is usually expelled eight to nine minutes after delivery. However, a prolonged time interval for placenta delivery can cause PPH.
- Invasive placenta: This could happen due to advanced maternal age, previous invasive placenta or c-section delivery, high parity, and placenta previa. This condition is further classified based on the depth of the invasion of the placenta into the uterine wall.
- Placenta accreta means adhering to the myometrium.
- Placenta increta means invading the myometrium.
- Placenta percreta means penetrating the myometrium to or beyond the serosa.
4. Thrombin (Blood clotting disorder): It is a rare cause of PPH. This disorder includes:
- Idiopathic thrombocytopenic purpura
- Thrombotic thrombocytopenic purpura
- Von Willebrand’s disease
- HELLP (hemolysis, elevated liver enzyme levels, and low platelet levels)
- Disseminated intravascular coagulation
How Is Postpartum Hemorrhage Diagnosed?
The doctor does a physical examination of your vagina, perineum, cervix, and the uterus to check for bleeding. Then, they may advise the following tests to diagnose postpartum hemorrhage:
- Blood tests to determine the red blood cell count
- Clot observation tests
- Blood clotting tests
- Monitoring the blood pressure and the pulse
- Measuring the blood loss by looking at the number of sponges or saturated pads that absorb the blood
The following section explains the treatment options for postpartum hemorrhage.
How Is Postpartum Hemorrhage Treated?
Depending on how severe the bleeding is, one of the following treatments is recommended (7):
1. Oxygen, fluids, or resuscitation: An oxygen mask and IV fluid are required. In the case of massive hemorrhage (>1000 to 1500 ml), a blood transfusion may be required.
2. Bimanual uterine massage: This technique is used in the case of loss of tone of the uterine muscles. A doctor performs this massage by placing a hand inside the vagina and pushing the uterus against its wall while using the other hand to compress the fundus from the outside. This contracts the uterus, thereby slowing down the bleeding.
3. Medication: The doctor may use oxytocin for contracting the upper part of the myometrium, thereby decreasing the blood flow. It is the initial treatment given for PPH and is administered by injecting 10IU intramuscularly or 20IU intravenously in one liter of saline. The flow rate is adjusted at 250ml/hour.
Methylergonovine (Methergine) and ergometrine are the other drugs for the uterine muscle contraction. About 0.2mg of methylergonovine is given intramuscularly at an interval of two to four hours. Ergometrine is not recommended for women with preeclampsia or hypertension.
Misoprostol is a prostaglandin that is effective in treating PPH. Its dosage ranges from 200-1,000mcg and the recommended dose for rectal administration by FIGO is 1,000mcg. Higher dosages are associated with side effects like pyrexia, shivering, and diarrhea.
In the case of blood clotting disorders, recombinant factor VIIa or medications such as tranexamic acid, which help in clotting, are considered.
4. Trauma Repair: In the case of:
- A tear in the genital tract or any other trauma, the doctor will stitch the tear. In the case of hematoma, the clot will be removed and the bleeding blood vessels will be tied up.
- Uterine inversion, the doctor will revert the uterus into the abdomen by lifting it up through the pelvis. Then uterotonic agents will be given to promote uterine tone. If the method fails at the first attempt, then terbutaline (Brethine), nitroglycerin, magnesium sulfate, or general anesthesia will be given to allow uterine relaxation. If it fails again, then surgery is the last option to reposition the uterus.
- Uterine rupture, hysterectomy (removal of the uterus) may be carried out.
5. Placenta removal: The placenta will be removed manually using analgesia in the case of retained placenta. However, the treatment for invasive placenta is a hysterectomy.
A massive hemorrhage might require one of the following surgical procedures:
- The B-lynch suture is a technique used for uterine compression, which is proven to be more effective. If the uterotonic drugs fail to treat uterine atony, then compression sutures are inserted promptly (8).
- Uterine packing is done, wherein a special tamponade device or sterile materials are put inside the uterine cavity to constrict the bleeding area
- Repair of arteries
- Uterine curettage involves scraping of the lining of the uterus
- Hematoma repair
- Removal of placenta remains
- Uterine artery embolization is a non-invasive procedure for blocking the uterine artery.
- Insertion of a balloon into the uterus to put pressure on the area where the placenta was attached.
- Iliac artery ligation is a surgical procedure that causes a drop in the arterial pressure and eliminates the Trip-hammer effect. This method also helps in preserving fertility (9).
Post delivery, you can certainly take some precautions to avoid the incidence of postpartum hemorrhage with the active management of the third stage of labor (AMTSL).
How Can Postpartum Hemorrhage Be Prevented?
AMTSL is an effective intervention for preventing PPH. It includes the administration of uterotonics, controlled cord traction, and uterine massage post placenta delivery (10).
- During a vaginal birth, administration of oxytocin (uterotonic drug) can help reduce the blood flow. It also helps in expelling the placenta from the wall of the uterus. After this, the doctor should check for any tears. If there is heavy bleeding, then stitches will be placed to reduce the blood flow (3).
- Gentle cord traction, wherein the cord is clamped close to the perineum, is done during the uterine contraction. This can reduce the chances of PPH.
- If you are anemic during pregnancy, then taking iron supplements help constrict the blood flow if you develop PPH.
If you have had a C-section previously, the doctor will check if the placenta is attached to the scar area in the subsequent pregnancy. If yes, it can make placenta expulsion difficult. In such a case, a team of professionals will evaluate your scan results and make a plan for your care.
In the case of blood clotting disorders, the management includes treatment of the underlying disease, evaluating coagulation status, supporting intravascular volume, and replacing appropriate blood components. Administration of clot-promoting medications (like tranexamic acid (Cyklokapron)) or recombinant factor VIIa may be considered (7).
You must be anxious to know what’s next if you have had a postpartum hemorrhage. The following section answers your query.What Happens After A Postpartum Hemorrhage?
Once the bleeding is controlled, you will be closely monitored for your condition. Blood tests will be done to check for blood clotting. Also, blood pressure and urine output will be measured. In the case of patients who were operated, the doctor will check for any internal bleeding. You will be looked after in the intensive ward and later moved to the postnatal unit after the doctor is assured of no further risk (11).
Can You Experience Postpartum Hemorrhage If You Had It Before?
Yes. The risk increases if you had PPH previously. It repeats in 1 out of 10 women. A blood test is done to check the blood count and if the doctor suspects PPH, a cannula is inserted in your leg vein to administer the medicine during labor
Although postpartum hemorrhage can be a cause of maternal mortality, the advancements in pharmacology have come up with effective solutions to lower the incidence of PPH. Following the active management measures can prevent PPH in several cases.