Postpartum hemorrhage (PPH) is a complication of delivery, when more bleeding than normal occurs in the genital tract after the birth of a baby. About one in 100 to five in 100 women have postpartum hemorrhage and it is a globally leading cause of maternal morbidity and mortality. In other words, the incidences of postpartum haemorrhage are 1-5 percent only. It most often happens after the placenta is delivered, but it can also happen later. Most deaths resulting from PPH occur during the first 24 hours after birth, however, the majority of these can be prevented by timely and appropriate management.
What causes postpartum haemorrhage?
Once a baby is delivered, the uterus normally contracts and pushes out the placenta. After the placenta is delivered, these contractions help put pressure on the bleeding vessels in the area where the placenta was attached. If the uterus does not contract strongly enough, these blood vessels bleed freely and as a result the proper constriction of the vessels does not happen and they keep bleeding profusely. This is the most common cause of PPH. If small pieces of the placenta stay attached, bleeding is also likely.
Postpartum hemorrhage may also be caused by:
Tear in the cervix or tissues of the vagina
Tear in a blood vessel in the uterus
Inversion of uterus
Blood clotting disorders
Who is at risk for postpartum hemorrhage?
Some women are at greater risk for postpartum hemorrhage than others. Conditions that may increase the risk include:
Placental abruption: This is the early detachment of the placenta from the uterus.
Placenta previa: This is when the placenta covers or is near the opening of the cervix.
Over-distended uterus. This is when the uterus is larger than normal because of too much amniotic fluid or a large baby.
Multiple foetuses like twins or triplets.
High blood pressure disorders of pregnancy
Having many previous births
Caesarean delivery (It is normal to lose a lot of blood during a cesarean delivery but when you bleed too much, this may be called a postpartum haemorrhage.)
What are the symptoms of postpartum hemorrhage?
These are the most common symptoms of postpartum hemorrhage:
Uncontrolled bleeding (If it happens within 24 hours it is called primary PPH. Most common time is immediately after delivery of the baby. After 24 hours to 6 weeks is called secondary PPH.)
Decreased blood pressure
Increased heart rate
Decrease in the red blood cell count
Swelling and pain in the vagina and nearby area if bleeding is from a hematoma.
It is a medical emergency and treatment includes immediate diagnosis of the cause and stopping the bleeding as soon as possible. Replacement of IV fluids, blood and blood products needs to be done simultaneously to prevent deterioration. It’s a serious condition but full recovery is possible with timely, quick treatment.
Massaging the uterus to make it contract.
Medicines to make the uterus contract should be immediately administered to the patient.
Breastfeeding the baby stimulates the nipple, which releases oxytocin and contracts the uterus.
Removal of the placental bits from the uterus.
Repair of tears in vagina and cervix.
Balloon tamponade (Bakri balloon) is used to put pressure inside the uterus on the bleeding vessels.
Uterine packing if the balloon is not available.
Uterine artery embolisation, if available in the hospital.
Surgery, if medical therapy doesn’t work. We may resort to laparotomy to save the patient. First, the vessels are tied. Hysterectomy (removal of uterus) may be done as a last life saving measure.
We have all heard the saying “Prevention is better than cure”. It is important to understand that delivering a baby is like a second birth to the mother and any delivery can turn into a complicated case at any point of time and these can arise either in antenatal or in postpartum phase.
Know your risks beforehand
Good nutrition- This goes a very long way to save a lot of hassles. Be aware of your nutrition before pregnancy also. When you become pregnant, be very careful of your nutrition. Get a good diet plan. Lots of protein, iron, calcium rich food builds your stamina to deal with complications.
Haemoglobin levels- Anaemia is very prevalent in India. If your Hb is good at delivery then you can tolerate a good amount of loss without effects on the body. So take an iron and protein rich diet along with the supplements provided by the doctor.
Good antenatal care lets you identify any problem quickly and deal with it
2-3 years gap between babies
Tertiary care- Choose your hospital carefully. The centre you choose must have the facilities to deal with any complications, it should be 24*7 functional with availability of gynaecologist, neonatologist, anaesthetist and other staff to handle emergencies. Blood products should be available, transport also maybe needed. 1 unit blood is usually arranged in every delivery however uncomplicated it may seem.
Postpartum haemorrhage : Quick things to know
Postpartum haemorrhage is heavy bleeding after the birth of your baby.
Minor PPH – When there is blood loss of 500-1000ml
Major PPH – when the blood loss is >1000ml
If mother is anaemic and malnourished then even a lesser amount of bleeding can affect her vital signs.
Losing lots of blood quickly can cause a severe drop in your blood pressure. It may lead to shock and death if not treated.
The most common cause of postpartum haemorrhage is when the uterus does not contract enough after delivery.
Quickly finding and treating the cause of bleeding can often lead to a full recovery.
Any amount of blood loss which causes changes in the birthing mother’s vital signs amounts to PPH and should be treated accordingly.
Once you have recovered from PPH, follow-up is required to build your health. You may require lab tests to see your iron stores. Work on your body in terms of nutrition and iron supplements so that the deficiency is covered well and you achieve your full potential as soon as possible. Last but not the least, the mental aspect also needs to be addressed as these traumatic events leave a lasting imprint on the psyche of the new mother. Family support, loving care and psychological counselling may be needed. You don’t need to be worried or stressed about giving birth, just be prepared for any event because becoming a mother is the best gift of being a woman in-spite of all the highs and lows.
(The writer is Senior Consultant – Obstetrician & Gynaecologist, Cloudnine Group of Hospitals, Chandigarh.)