Postpartum Haemorrhage (PPH): An Overview

There are several complications that can occur during or after delivery, and postpartum haemorrhage (PPH) is one of these. This usually happens after the placenta is delivered and is more frequently associated with Caesarean deliveries. Postpartum haemorrhage usually takes place immediately after delivery, but in some instances it can happen much later. Here’s everything you need to know about postpartum haemorrhage and when you need to see a doctor.

What is Postpartum Haemorrhage (PPH)?

Bleeding after giving birth is normal, but when this becomes excessive, it could indicate a case of postpartum haemorrhage (PPH). A leading cause of maternal mortality, postpartum haemorrhage happens when there is a loss of more than 500 ml of blood after a vaginal delivery. In a Caesarean delivery, the average amount of blood loss is 1,000 ml and anything above this constitutes postpartum haemorrhage. Postpartum haemorrhage can be classified into two— primary postpartum haemorrhage and secondary postpartum haemorrhage.

• Primary PPH – It is said to be primary PPH when the blood loss occurs within 24 hours of delivery.
• Secondary PPH – This is when the excessive blood loss occurs any time after 24 hours have passed and until 6 weeks past delivery.

Signs and Symptoms of Postpartum Haemorrhage

Postpartum haemorrhage symptoms can vary from woman to woman. The following are some common indications to watch out for:

• Bleeding that cannot be controlled
• Drop in blood pressure
• Higher heart rate
• Dip in the red blood cell count
• Swelling in the genital area
• Pain in the tissues around the vagina and perineal region

Causes of Postpartum Haemorrhage

Bleeding after delivery is common as the uterus continues to contract and eventually expels the placenta. In some instances, the uterus fails to contract after giving birth to the baby, leading to excessive bleeding of the blood vessels. Known as uterine atony, this can cause haemorrhage and is the most common cause of primary PPH. Excessive bleeding can also occur when small pieces of the placenta remain attached. Other causes include:

• Tearing of the cervical or vaginal tissues
• A tear in a uterine blood vessel
• A hematoma in the vulva or vaginal region caused by bleeding into a concealed tissue area or space in the pelvis
• Blood clotting disorders which are inherited or caused by pregnancy complications
• An inverted uterus
• Placenta accreta, where the placenta is abnormally attached to inner side of the uterus
• Placenta increta, where the muscles of the uterus are invaded by placental tissues
• Placenta percreta, where placental tissue burrows into the uterine muscle and may also rupture

Uterine rupture is a life-threatening condition and risks of this happening are higher in those who have had previous surgery for fibroid removal or a C-section.

Conditions That Increase the Risk of Postpartum Haemorrhage

Some types of pregnancy complications can increase your risks of experiencing postpartum haemorrhage.

• Prolonged labour,
• Having given birth many times previously,
• Obesity
• Infection
• Placental abruption, where the placenta detaches from the uterus much ahead of schedule and
• Placenta previa where the placenta moves near the cervical opening, at times covering it
• A multiple pregnancy
• Over distended uterus as a result of a very large baby
• Medications to induce labour or stop contractions
• Use of forceps or vacuum during delivery

How Long Do You Bleed After Delivery?

After birth, the body gets rid of the lining of the uterus and this is why you bleed after delivery. The bleeding can last anywhere between 2 and 6 weeks after having a baby. It resembles a heavy period and can come out in gushes or an even flow. Known as lochia, at first, it is heavy and bright red but will gradually change colour to pink and then brown. Soon, it will turn to yellow-white and the flow will start tapering off.

Diagnosis of Postpartum Haemorrhage

Symptoms and blood tests are crucial in making a diagnosis of postpartum haemorrhage. Your medical history as well as a physical examination will help the doctor arrive at a conclusion. The doctor will also need to know details of the pregnancy, labour, and delivery before arriving at any conclusion. Examination of the birth canal will help the doctor determine if there is any trauma. The placenta will have to be checked for completeness while assessing the uterine size is also essential for arriving at a diagnosis. The tests conducted are likely to look at the clotting factors of blood, the red blood cell count, pulse rate, blood pressure, and estimation of blood loss.

Postpartum Haemorrhage Treatment

The treatment of PPH will vary depending on factors like your overall health, medical history, and the extent of your condition. The intention of the treatment is to pinpoint the cause of the haemorrhage and stem it. The course of treatment can include:

• Medications to start uterine contractions is administered.
• Massaging the uterus manually to induce contractions is suggested.
• Extraction of residual placental pieces from the uterus is carried out.
• A detailed examination of the uterus and other pelvic tissues follows.
• A Bakri balloon or a Foley catheter may have to be used to stem the bleeding inside the uterus.

• The doctor might tie off the bleeding blood vessels with uterine compression sutures.
• A laparotomy may have to be done which involves surgically opening the abdomen to locate the cause of bleeding.
• As a last resort, a hysterectomy might have to be done in certain cases.

Complications of Postpartum Haemorrhage

Certain factors like the amount of blood lost, your health before the haemorrhage started, and the type of treatment available will be crucial in determining if there will be any complications. Complications of PPH are Sheehan’s Syndrome, severe anaemia, and in some cases, maternal death.

In Sheehan’s Syndrome, severe loss of blood cuts down the blood supply to the pituitary gland that can cause cells to die. PPH tends to be dangerous for those with anaemia and might necessitate a blood transfusion. Those with prior conditions that put them at risk of postpartum haemorrhage are more likely to develop complications.

Preventive Measures

The use of uterotonics or medications that cause uterine contractions is recommended by the WHO for the prevention of PPH. Active management of the third stage of labour, especially in C-sections and in cases where there is a lack of skilled birth assistants is also considered crucial to the prevention of postpartum haemorrhage. Opting for cord traction instead of manual removal has also been found to prevent PPH.

Apart from this, it is also suggested that you follow good prenatal nutrition and supplementation practices throughout the pregnancy to reduce the risk by treating health problems such as anaemia and hypertension.

Postpartum Haemorrhage Management

Assessment of previous and ongoing blood loss as well as vital signs such as pulse and blood pressure is important to the management of PPH. You will have to be admitted to hospital and kept under observation for a few days while being administered IVs and medications. If this is the case, then a suitable nursing care plan for postpartum haemorrhage can be worked out in consultation with your physician.

Conclusion

Postpartum haemorrhage is a serious condition but timely diagnosis and treatment can lead to a full recovery gradually. The pace of recovery will largely depend on the amount of blood lost as well as your health before and during the pregnancy. A good deal of rest, adequate intake of fluids, and healthy, nutritious food will help you get back on your feet quicker.

Disclaimer: This information is not intended as a substitute for medical advice from a qualified professional.