Postpartum Hemorrhage (PPH)
(Bleeding after Childbirth)
Written by : Dr.M.D.Mazumdar, MD
Postpartum haemorrhage is defined as excessive bleeding occurring at any time from the birth of the baby upto 6 weeks after delivery. The bleeding loss has to be greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section to be labelled as postpartum hemorrhage. This amount is usually sufficient to affect the general condition of the woman.
There are two clinical types of postpartum hemorrhage:
- Primary postpartum hemorrhage.
- Secondary postpartum hemorrhage.
Primary Postpartum HemorrhagePrimary postpartum hemorrhage is defined as bleeding that occurs within 24 hours of the birth of the baby. This is again divided into two types:
- Third Stage Haemorrhage:This is primary hemorrhage that occurrs after the delivery of the baby but before the expulsion of the placenta.
- True Primary Postpartum Hemorrhage: This is hemorrhage that occurs after the delivery of the placenta at any time within 24 hours of the birth of the baby. The majority of the cases of postpartum hemorrhages fall in this category.
Secondary Postpartum HaemorrhageBleeding that occurs after 24 hours of the delivery of the placenta upto 6 weeks after the delivery is called secondary postpartum hemorrhage. This condition will not be described in this page.
Causes of Primary Postpartum Hemorrhage
- Atonic haemorrhage - 'Atonic' means lack of tone of the muscles or flabby muscles. Failure of the muscles of the uterus to contract properly after the placenta has been delivered is the commonest cause of postpartum hemorrhage. It accounts for about 80% of all cases.
Causes of Atonic Postpartum Hemorrhage are:
- Partial or complete retention of the placenta
- When the muscles of the uterus are exhausted after prolonged labour.
- Overdistension of the uterus as in cases of twin pregnancy or hydramnios
- Tumours like fibroids preventing proper contraction of the uterine muscles
- Repeated pregnancies can cause the uterine muscles to become lax and hemorrhage to occur in the later pregnancies.
- Traumatic Haemorrhage : Bleeding can occur from maternal injuries like cervical, vaginal or perineal tears. While minor tears cause only a minimal bleeding which is easily controlled, deep tears may need to be examined and repaired under anesthesia.
- Mixed PPH: Postpartum hemorrhage is frequently a mixture of both atonic as well as traumatic hemorrhage. Many of the factors that contribute to the laxity of the uterine muscles are also factors that contribute to injury of the birth canal.
- Blood Coagulopathy: Blood coagulopathies like decreased level of platelets in the blood (thrombocytopenia), Factor V Leiden, Von Willebrand's disease are conditions that decrease the ability of the blood to form clots. This can lead to severe hemorrhage.
Management / Treatment of Primary Postpartum Hemorrhage
The main principles of management are:
(a) Prevention of further blood loss.
(b) Restoration of proper blood volume.
(c) Repair of the injured tissues.
(D) Stimulating contraction of the uterine muscles.
Treatment depends on whether the bleeding has occured before the placenta has separated from the uterine wall and been delivered or whether the placenta is still in place inside the uterus (Retained Placenta).
- Controlled cord traction is given to try and deliver the placenta, especially in a case of home delivery.
- If the above method fails, manual removal of the placenta should be done under general anesthesia in the operating theatre.
Where the placenta has been delivered but bleeding is still present:
- Bimanual palpation of the uterus by gripping it with one hand over the abdomen and the other placed in the vagina stimulates the uterus to contract. Any large clots or tissue present in the lower part of the uterus that are preventing adequate contractions can be removed by the gloved hand.
- Oxytocin is given IV and Methargine is injected. Misoprostol is also very good drug to cause uterine contractions.
- IV fluids are started , especially with crystalloids and the woman put on oxygen. The patient must be treated as any other case of hemorrhagic shock.
- The cervix, vagina and perineum is examined under proper light for any tears and injuries and if present, they are repaired.
- An ultrasound is done to see if the uterus is completely empty of any placental contents. If present, they are removed under GA.
- In suspected cases of uterine rupture, the patient needs to be examined and the rupture repaired in the OT under general anesthesia.
- Occasionally, in rare intractable cases, a hysterectomy (removal of the uterus) may be the only option left.
- General support of the patient.
- Sheehan's Syndrome.
- Female Anatomy - the vulva, the clitoris etc.
- Diet in Pregnancy .
- Vulvar Hematoma.