Postpartum hemorrhage (PPH) refers to heavy bleeding after childbirth – 500ml blood loss in a vaginal delivery and 1000ml blood loss in a C-section. It happens immediately after the delivery of the placenta but may also occur after a few days to weeks. Approximately one in 100 to five in 100 women suffer from PPH, and it is more common in cesarean than vaginal deliveries (1).
PPH is a major cause of maternal death worldwide (2). Early identification can help in timely and adequate treatment. This post will help you understand its types, causes, signs and symptoms, management, and after-care.
Types Of PPH
- Primary or early PPH
PPH is when one loses 500ml of blood or more within 24 hours of delivery. It is minor if one loses about 500 to 1000ml of blood and major if one loses more than 1000ml of blood.
- Secondary or late PPH
It occurs 24 hours to 12 weeks after delivery.
More than 99% of all cases of PPH are early postpartum hemorrhage.
Causes Of PPH
Once the child is delivered, the uterine contractions push the placenta out. Following this, the uterine contractions exert pressure on the blood vessels present at the site of placenta attachment. If the uterus does not contract well, blood continues to flow from these blood vessels. It is the most common cause of PPH. Bleeding is also likely if small remnants of the placenta are left attached to the uterus.
The following causes may also lead to PPH (5)
- A cervical tear or tear in the vaginal tissues
- A tear in the blood vessels of the uterus
- Bleeding in a hidden tissue area or pelvic space, usually in the vulva or vagina. This mass of blood is called a hematoma.
- Coagulation disorders such as Von Willebrand disease or disseminated intravascular coagulation (DIC)
- Problems with the placenta
- Uterine inversion, a rare condition where the uterus turns inward after birth.
- Uterine rupture is a rare condition where the uterus may tear during labor. It may happen if you have a scar in the uterus from previous surgery on the uterus.
Risk Factors For PPH
- Placental abruption: Premature detachment of the placenta from the uterus.
- Placenta previa: Placenta completely covers or is close to the cervical opening.
- Placenta accreta: Placenta grows into the wall of the uterus too deeply and becomes inseparable.
- Retained placenta: Placenta does not deliver within 30 to 60 minutes after childbirth.
- Overdistended uterus: Uterus is larger than normal because of excessive amniotic fluid or a larger baby.
- Prolonged labor: Labor for several hours or augmented labor (when medications or other means are used to increase contractions)
- Pregnancy with multiples (twins, triplets)
- High blood pressure in pregnancy
- History of several childbirths
- Infections such as chorioamnionitis
- Preeclampsia or gestational hypertension
- Forceps or vacuum-assisted delivery
- Asian or Hispanic ethnicity
However, PPH may also occur in patients with no known risk factors (7).
Symptoms Of A Postpartum Hemorrhage
Some common symptoms of postpartum hemorrhage include (5):
- Uncontrolled bleeding
- Low blood pressure
- Increased heart rate
- Reduced red blood cell count
- Swelling and pain in and around the vagina if the bleeding is happening from a hematoma.
Signs You Should Call Your Doctor
While most cases of PPH occur immediately after childbirth, some women may develop the symptoms after a period. Contact your doctor immediately if you notice any of these symptoms from childbirth to the next 12 weeks (5).
- Vaginal bleeding that necessitates a change of pad every hour, or if you pass large blood clots.
- Lightheadedness, dizziness, or faintness.
- Belly pain that is new or is getting worse.
- Unusual tiredness.
- Fast heartbeat or pulse.
- Blurry vision.
Diagnosis Of PPH
Your healthcare provider will do a thorough review of your health history and a detailed physical examination. Other tests may include (5).
- Amount of blood loss
- Pulse and blood pressure measurement
- Red blood cell count
- Clotting factors in the blood.
Management Of PPH
- Intravenous fluid administration
- Picotin (oxytocin) injection (it is a natural hormone that helps in uterine contractions and controlling bleeding after childbirth)
- Getting a blood transfusion
- Giving uterine massage to stop uterine bleeding and also help the body pass blood clots
- The healthcare provider would remove any remnants of the placenta from the uterus
- A Bakri balloon or a foley catheter may exert pressure on the bleeding vessels in the uterus. If they are not available, the doctor may stuff the uterus with a sponge or sterile materials to stop the bleeding.
- The doctor might use special tests to find the affected blood vessel and inject medicines into the vessel to stop bleeding.
- Laparotomy (an open abdominal surgery) can be performed to identify the cause of bleeding.
- As a last resort, the uterus may be surgically removed (hysterectomy).
Complications Of PPH
Rapid loss of a large amount of blood can cause a drastic drop in blood pressure. If untreated, it may also lead to shock and death (5).
Prevention Of PPH
If you are at a high risk of developing PPH, it is essential to keep all emergency care available that could need at the time of childbirth or immediately after birth. Prompt care and intervention can reduce blood loss (5).
According to the World Health Organization (WHO), the majority of deaths occurring in the first 24 hours after birth due to PPH can be avoided by active management and use of prophylactic uterotonics (drugs used to induce contraction of the uterus) during the third stage of labor (8).
Care After PPH
If you develop PPH, you may need a longer hospital stay. If the doctor suspects you to be anemic, you may be advised to continue iron supplements for several weeks after delivery. You may be asked to get your blood counts re-evaluated six to eight weeks after you go home.
You are at a higher risk of developing blood clots in your lungs and legs. The doctor may prescribe blood thinner injections and compression stockings for ten weeks after delivery to avoid these clots.
You should take ample rest and keep realistic expectations. The recovery is slow but achievable with care and rest (4).
Frequently Asked Questions
1. What happens after a postpartum hemorrhage?
Once bleeding is controlled, the doctors and nurses will closely monitor you for any worsening in the condition. More blood tests may be performed to ensure if your kidney function and blood clotting are normal. Blood pressure, pulse, urine output, and vaginal bleeding will be closely monitored. You may be admitted to an ICU initially, and as the high-risk time passes, you may be shifted back to your room with the baby (9).
2. Can I have another baby after a postpartum hemorrhage?
Yes, you can have a baby again after a postpartum hemorrhage (10).
3. How does PPH lead to death?
When one loses a lot of blood rapidly, there is a significant drop in blood volume and blood pressure, resulting in shock and death.
4. Can I experience postpartum hemorrhage if I had it before?
Yes, you are at an increased risk of developing PPH again if you have a previous history of PPH (11).
PPH is a serious and life-threatening complication. However, it can be avoided using necessary precautions and measures. If you have a history of PPH or have any other risk factors that may make you more susceptible to PPH, inform your healthcare provider about it. If you experience PPH after childbirth, take ample rest and follow all the instructions given by your doctor. If you notice any unusual symptoms after discharge, reach emergency care as soon as possible or call the local emergency number.
- Postpartum hemorrhage is characterized by severe bleeding after delivery and is more common in cesareans.
- It is divided into two types and can occur due to uterine blood vessel tear, detached or retained placenta, and cervical tear.
- Non-stop bleeding, decreased blood pressure, or vaginal pain can indicate a postpartum hemorrhage.
- A physical examination and specific blood tests may be carried out, followed by different treatments depending upon the cause.
- Postpartum Hemorrhage.
- Rodolfo Carvalho Pacagnella Anderson Borovac-Pinheiro; et al; (2019); Assessing and managing hypovolemic shock in puerperal women.
- What are the types of postpartum hemorrhage (PPH)?
- Heavy bleeding after birth (postpartum haemorrhage).
- Postpartum Hemorrhage.
- POSTPARTUM HEMORRHAGE.
- Lill Trine Nyflot, et al; (2017); Risk factors for severe postpartum hemorrhage: a case-control study.
- WHO Recommendations on Prevention and Treatment of Postpartum Haemorrhage and the WOMAN Trial.
- Postpartum haemorrhage.
- No higher risks after heavy postpartum bleeding.
- Postpartum haemorrhage.