Postpartum Haemorrhage: What is it, what are the risk factors for it occurring and how should it be managed?

What is postpartum bleeding or postpartum haemorrhage?

A primary postpartum haemorrhage (PPH) is defined by the World Health Organisation as the loss of 500mls or more of blood from the genital tract within 24 hours of the birth of a baby.  It is possible for haemorrhage to occur after 24 hours (between 24 hours and 12 weeks after the birth of a baby) and this is referred to as a secondary postpartum haemorrhage.

It is common for woman to lose some blood following childbirth which is generally understood to be due to the placenta separating from the uterus.  Woman who have caesarean sections generally lose more than those who give birth vaginally.  However, because the amount of blood in the body increases by almost 50% during pregnancy, the body is well prepared to deal with this expected blood loss.  Normal bleeding just after childbirth is primarily from open blood vessels in the uterus, where the placenta was attached.

Postpartum haemorrhages occur when woman bleed too much and it is this excessive blood loss that is referred to as a postpartum haemorrhage.  Postpartum haemorrhage is reported to occur in up to 6% of births.  It is most likely to occur while the placenta is separating or soon after.

What should happen if a postpartum haemorrhage occurs?

The Royal College of Obstetricians and Gynaecologists (RCOG) has released guidelines on the management of postpartum haemorrhages.  They advise that primary postpartum haemorrhage involving estimated blood loss of 500 – 1000mls should prompt basic measures, including close monitoring, oxygen and IV access, full blood count, group and save to facilitate resuscitation should it become necessary.  Further, if a woman with primary postpartum haemorrhage continues to bleed after her estimated blood loss of 1000mls, this should prompt full protocol measures to achieve resuscitation and haemostasis.

If the bleeding is considered to be due to uterine atony then a number of measures can be instituted to attempt to stop the bleeding.   The uterus may be compressed and massaged, the bladder emptied, medications such as Syntocinon, Ergometrine, Carboprost may be administered.  If these pharmacological measures fail to control the haemorrhage then it may be necessary to progress to surgical measures.  A balloon may be inserted into the uterus and a “B-lynch suture” put in place to try to prevent the bleeding.  Further surgical measures include bilateral ligation of the uterine arteries, internal iliac arteries, selective arterial embolisation or resort to a hysterectomy “sooner rather than later”.  It is necessary for a second consultant clinician to be involved in the decision for a hysterectomy.

The RCOG Guidelines indicate that the care plans must be modified when risk factors which are known about in the ante-natal period or intra-partum period become evident.

Once PPH has been diagnosed, good communication, resuscitation and the arrest of the bleeding should take place.

What might cause a postpartum haemorrhage?

There are a number of potential causes and risk factors for PPH, these include:

• Cervical lacerations, deep tears in the vagina or perineum, or episiotomy;
• Ruptured or inverted uterus may cause profuse bleeding but these are relatively rare occurrences;
• Blood clotting disorders – A clotting disorder may be an inherited condition or it may develop during pregnancy as a result of certain complications, such as severe pre-eclampsia or HELLP syndrome or a placental abruption;
• Delivery by emergency caesarean section;
• Operative vaginal delivery;
• Prolonged labour (in excess of 12 hours).

With secondary postpartum haemorrhage the bleeding is usually less severe.  The cause is often uterine atony or ‘retained products or conception’ – where placental or fetal tissue remains in the uterus.  A full blood count, midstream urine, high vaginal swab and ultrasound can be used to detect retained products of conception.

What are the potential complications?

Obstetric haemorrhage remains one of the major causes of maternal death in both developed and developing countries.  It is therefore an emergency situation requiring prompt action by those caring for the patient.  Complications include; shock; renal failure; sepsis; fluid overload; DVT; hysterectomy and sadly maternal death.  There have been a number of national enquiries into the causes of maternal deaths with PPH being reported as a common cause and, in many cases, entirely preventable with proper care.  I have acted for a number of clients who have suffered PPH causing complications including some requiring hysterectomies.  In addition to the physical injuries, my clients also often suffer psychological trauma which can last for many years.

The RCOG Guidelines have been in place for a number of years and are frequently being updated, including a new update due next year, to reflect changing practice and, if followed, should hopefully ensure that the numbers of women suffering such complications are kept to a minimum.