Postpartum Haemorrhage

All women lose blood after delivery but your body is well prepared to deal with a certain amount of blood loss as the total blood volume increases by almost 50% during pregnancy.

A postpartum haemorrhage (PPH) is when excessive heavy bleeding occurs after birth (more than 500ml of blood).

A primary PPH occurs within the first 24 hours of birth and a secondary PPH occurs from between 24 hours and six weeks post-delivery.

It is thought that between 5 – 15% of all births result in a PPH.

Blood loss immediately after delivery occurs when the placenta tears away from the uterine wall and is expelled usually within 5 – 30 minutes after giving birth. The exposed area of the uterine wall where the placenta was attached is a large raw area with exposed blood vessels. The uterus contracts due to the hormones released by the body and an injection of uterine contracting hormones. This places pressure on these exposed vessels which causes them to collapse. At this stage the bleeding usually settles.

A PPH occurs when this bleeding continues. The most common cause of a PPH is uterine atony which means that the uterus is not contracting efficiently after delivery. Other causes may be a tear or damage to the vaginal wall, trauma to the cervix or uterus or retained portions of the placenta or membranes remaining inside the uterine cavity. Rarely a systemic blood clotting disorder may cause haemorrhage. This may be an inherited condition or one that develops during pregnancy from complications such as severe pre-eclampsia, HELLP syndrome or a placental abruption (acute seperation of the placenta from the uterine wall).

Whilst PPH is a serious complication following delivery and extremely difficult to predict, it is important to identify those at risk.

• Women having long labours, large babies or assisted vaginal deliveries are at greater risk.
• All women should be tested for iron deficiency anaemia during pregnancy and be prescibed iron supplements if necessary. We know that being iron deficient prior to delivery is an associated risk for PPH.
• Being aware of women who have had a previous PPH, have a multiple pregnancy or are having their fifth or more pregnancy.

Despite these antenatal observations, the majority of women who experience a PPH are not in these high-risk groups.

Active management of the third stage of labour (the delivery of the placenta) has been shown to reduce the occurrence of PPH.

This management includes:

• The administration of an injection of a drug Oxytocin which aids in the contraction of the uterus
• Assist with the delivery of the placenta by using gentle traction
• Following this management if the bleeding does not settle further steps are taken quickly and include:

-The uterus is massaged to stimulate a contraction.

-Insertion of IV lines to replace fluid loss

-A further dose of Oxytocin will be administered
-A urinary catheter will be inserted to drain urine from your bladder. A full bladder will inhibit the uterus to contract.
-The vagina, cervix and perineum will be closely examined to ensure that a laceration or trauma is not the source of bleeding
-The placenta and membranes will be examined to ensure they are complete and that there are no fragments missing which could indicate they have been retained
-These steps are usually sufficient to cease any further episodes of bleeding.

In rare cases where the bleeding does not stop or the woman’s vital signs are not stable, it may be recommended that a procedure called a EUA (examination under anaesthetic) be performed. This way a thorough examination of the uterus can be performed through the vagina and any retained products or large blood clots can be removed. Very occasionally if the blood loss is not contained by these measures a balloon catheter is inserted into the uterus. This creates pressure against the uterine wall to compress blood vessels and encourage blood clotting.

Once the bleeding is deemed to be under control, the woman is transferred back to ward and closely monitored. The IV, catheter and balloon are usually removed the following day. Close observation and a full blood count will be taken to access the possible need for a blood transfusion should the iron level be low. The postnatal period from here should continue as normal but an extra day or so in hospital may be beneficial.

If any heavy bleeding occurs following discharge from hospital, the woman should seek medical advice immediately. We consider bleeding to be excessive if you fill a pad every 30- 60 minutes with bright blood.

As infection is a common cause of a secondary PPH, a course of antibiotics and possible readmission to hospital is required. We would check to ensure that there are no retained products of the placenta and membranes by performing an ultrasound. A curette may need to be performed if retained products are found. In many cases this form of bleeding will settle with simple measures.

It is important to remember that bleeding is a normal event after giving birth. The loss usually subsides by the six-week mark but bleeding may increase once you are home and increasing the level of physical activity.

If you are concerned at any time, always contact our office during work hours and speak to one of our midwives. After hours you may contact Dr Kliman via his paging service.