Postpartum Haemorrhage: Causes & Treatment

What is Postpartum haemorrhage?

Postpartum haemorrhage (postnatal bleeding) is the excessive bleeding from the woman’s genital tract of about 500mls or more following childbirth. Or it can be seen as any amount of bleeding occurring after the birth of the baby which deteriorates the maternal health state following birth of the baby up to 6 weeks after birth

Postpartum haemorrhage is the one of the types of obstetric haemorrhage. Remember that obstetric haemorrhage is defined as the blood loss during pregnancy, labour or within the days of pregnancy termination (delivery or abortion). Obstetric haemorrhage accounts 25% of maternal death globally and 90% in developing countries — which are often attributed to DELAY and lack of proper facility for obstetric emergencies.

This article would be very lengthy. Hence, consider the table of contents below for quick overview:

Signs and symptoms of PPH

• Bleeding per vagina (either acute blood loos or minimal bleeding for  long period)
• Tachycardia
• Shock
• Abdominal cramps and tenderness
• Pelvic pain and fever

Causes of Postpartum Haemorrhage (PPH)

PPH is caused by 4 “T” s as follows: Tone, Trauma, Tissue and Thrombin.

Tone: This is most common cause of post-partum haemorrhage. It is bleeding due to lack of uterine muscle tone, interfering with contraction of the uterus. It is known as uterine atony and predisposing factors are;

• Grand multiparity
• Over-distension of the uterus due to multiple pregnancy, polyhydramnios, fetal macrosomia.
• Previous history of post-partum haemorrhage.
• Ante partum haemorrhage
• Multiple fibroids
• Prolonged labour
• Full bladder
• Mismanagement of third stage of labour
• Operative deliveries such as caesarian section especially when halothane is used as anaesthesia.

Trauma:

• Uterine inversion
• Lacerations of the perineum, vagina and CX
• Ruptured uterus
• Too early episiotomy

Tissue:

• Retained placenta, placental tissue or membranes
• Incomplete separation of placenta

Thrombin: Coagulation failure interfering with blood clotting mechanism e.g., DIC

Risk factors of PPH

Alternatively, PPH is associated with:

Before delivery

• Ectopic pregnancy
• Gestational trophoblastic disease(hydatidiform mole or molar pregnancy)
• Abortion either spontaneous or incomplete
• Antepartum haemorrhage caused by abruptio placenta, placenta praevia or Vasa praevia

 After delivery

• Coagulopathy/coagulation failure
• Ruptured uterus
• Genital trauma or lacerations (e.g. cervical tear)
• Uterine atony  related to over-distension (e.g. Multifetal pregnancy, polyhydramnios)
• Retained products of pregnancy (placenta pieces or membranes)

How common is postpartum haemorrhage?

PPH occurs in less than 1% of all births and constitutes the key leading cause of maternal death. PPH remains one of the major obstetric concerns because of the following:

• Obstetric haemorrhage is world’s leading cause of maternal mortality, causing up to 127,000 deaths of women annually.
• 14 million cases of obstetric haemorrhage occur in the world annually
• In Nigeria 20 – 35% of maternal mortality is due to haemorrhage depending on geographical area (geo-political zone).
• Haemorrhage during first 4 hours after birth causes most of the death as a result of haemorrhage.
• Post-partum haemorrhage is unpredictable and rapid.
• Babies born to women who die following child birth die soon.

 Types of postpartum haemorrhage (PPH)

Post-partum haemorrhage may be primary or secondary.

• Primary postpartum haemorrhage
• Secondary postpartum haemorrhage

Primary postpartum haemorrhage

Primary Post-Partum Haemorrhage is defined as excessive blood loss from genital tract greater than 500ml occurring during third stage of labour till with 24 hours after delivery. It is a haemorrhage occurs during the third stage of labour and within 24hours of delivery

Secondary postpartum haemorrhage

Secondary PPH is the abnormal or excessive bleeding from the genital tract after 24hours to about 6-8weeks postpartum period. It is an excessive bleeding after 24hours of birth but within 42 days of the puerperium.

Secondary postpartum haemorrhage otherwise called puerperal haemorrhage is far more likely to occur within 10-14 days after delivery but tends to be less severe when compared to primary postpartum haemorrhage.

Symptoms of secondary postpartum haemorrhage

Secondary PPH may be associated with these:

• Persistent heavy lochia
• Foul-smelling/offensive lochia if there is infection
• Lochia that changes from serious pink/brownish discharge to bright red blood loss following the second week of puerperium
• Severe abdominal cramps
• Uterine subinvolution
• Pyrexia/fever and presence of tachycardia

Causes of Secondary PPH

• Unremoved large uterine blood clots
• Retained products of pregnancy (e.g. placenta fragments or chorionic membranes)
• Puerperal/postpartum sepsis/intrauterine infections (e.g. endometritis, para-endometritis, myometritis)
• Uterine fibroid or polyps which may be infected after delivery and thus result in secondary PPH and/or prevent the prevent effective involution which increases the chance of bleeding and abdominal cramps.(i.e. infected and slough from a sub-endometrial fibromyoma —fibroid)
• Puerperal inversion of the uterus: This may be sub-acute partial inversion occurring between 24hours to 30 days following birth or chronic when it occurs after 30 days postpartum.
• Undiagnosed carcinoma (cancer) of the cervix: During pregnancy, there is an increased blood supply to the cervix and or engorged veins in the cervix — which all prevent the early diagnosis of cervical cancer during pregnancy. A woman with bleeding or spotting on and off during puerperium should be tested for cervical carcinoma and treated promptly.
• Separation of septic slough from vaginal or cervical tear, placental site or Caesarean section wound

Note: The cervical os usually remains patent (opened) when something is retained in the uterus.

Secondary postpartum haemorrhage management

• Reassure the woman and her family
• Empty the woman’s bladder
• Observe the pads and linens to estimate the blood loss
• Encourage frequent breastfeeding to increase the release of oxytocin
• Expel blood clots and remove any placenta fragments or membranes
• Provide close monitoring of the woman and check her vital signs timely
• Administer intravenous infusions based on her condition
• Encourage bed rest and adequate nutrition
• Administer oxytocic medicines like Pitocin or ergometrine to boost uterine contractions and arrest bleeding
• Collect high and low Vaginal swabs and send for investigations
• Give her antibiotics based on her result of culture and sensitivity.
• Send for full blood count, grouping and cross-matching
• Transfuse her when necessary
• Give follow-up appointment and healthy advice on discharge.

Vulval haematoma

Vulval haematoma is a condition where there is a concealed traumatic haemorrhage into the connective tissues of the vulva and vaginal wall.  It is caused by rupture of subcutaneous vessels, which can manifest few hours after delivery. While a small vulval haematoma may be attributed to repair of medio-lateral episiotomy or laceration.  

Woman with vulval haematoma usually complains of discomfort and pain in the labia and/or perineum.  The skin of labia becomes thin —making haematoma to bulge into the vagina.

How to treat vulval haematoma

• Apply a hot saline pack
• Incise and drainage the haematoma
• Arrest bleeding vessels
• Offer blood transfusion if bleeding is severe

Complications of Postpartum haemorrhage

• Anaemia
• Sepsis/infection
• Hypovolemic shock
• Sheehan’s syndrome
• Acute kidney injury or failure
• Liver failure
• Disseminated intravascular coagulation
• Maternal death.

Principles of management of Postpartum haemorrhage

Principles for managing PPH include the following:

• Resuscitation
• Specific treatment
• Treatment of complications

Resuscitation (and Rapid Assessment)

1. Shout for help
2. Evaluate the woman rapidly (palpate the uterus to see if contracted, vital signs TPR, BP and pallor, rub fungus for contraction.
3. Ascertain the state of the woman if she is in shock or if she is not yet in shock.
4. Notify the obstetrician (medical aid)
5. Resuscitate the woman.

Calling for medical aid is an important first step to take. Once PPH occurs after delivery, send for obstetrician or a doctor while you get everything in control before the arrival of the doctor there is no problem. Reason for sending aid on time is that the woman’s condition may worsen and the woman may lose her life within few hours.

If you are in the community, plan to refer the woman to hospital as you take initial measures to stop the bleeding

Stop Bleeding:

 This involves the following steps:

• Rub uterus to contraction
• Give uterotonics to maintain contractions
• Empty the uterus

Rub uterus to Contraction:

• Ensure that the baby is put to breast with 1 hour of delivery.
• Feel the fungus of the uterus to assess its consistency
• If soft and relaxed (flabby), massage with gently circular motion for 15 seconds (till uterus is contracted).
• Hold the fungus for some time when contracted
• Ensure the bladder is emptied as full bladder will inhibit contractions.

Give uterotonics

• First drug of choice is oxytocin. Give oxytocin 10IU and add 40 IU into 1 litre of normal saline or Ringer’s lactate to run at 60 drops per minute as loading dose.
• If oxytocin is not available give ergometrine or syntometrine 1mg intramuscularly but it is contraindicated in women with pre-eclampsia and cardiac problems.
• The third drug of choice for sustaining contraction is misoprostol (Cytotec). Give – 600mcg (3 tablets), sublingually under the tongue or 1000mcg (5 tablets) rectally as loading dose. Misoprostol is contraindicated on asthmatic and cardiac patients.

Empty the uterus

Once the uterus is contracted, the midwife ensures that uterus is empty.

• If placenta has been delivered, all clots should be expelled by pressing the fungus with gentle firm pressure.
• If there is any missing lobe of placenta or membrane retained it must be removed.
• If placenta is still undelivered check if it separated or not.
• If separated deliver by controlled cord traction.
• If it is separated and is in the cervix or vagina grasp the bulk of the placenta and remove.
• If the placenta has not separated, proceed with manual removal of placenta.
• If she is in shock start immediate resuscitation before set up IV.
• Ensure airway is open.
• Check breathing and give oxygen by face mask.
• Check circulation and ask your assistant to set up IV-line normal saline or Ringer’s lactate to flow rapidly 1 litre in 30 minutes at least 2litres of fluid in the first 1 hour.
• Apply anti-shock garment
• Monitor BP and urinary output every 15 minutes until patient’s condition stabilizes.
• Take history of bleeding
• Assess patient to identify cause of PPH by performing physical examination, check for uterine contraction, and do perineal inspection to check for laceration.
• Note if placenta has been delivered and state of placenta and membranes. If placenta is available check for completeness.

If the woman is not shock

• Ask the assistant to set up IV line and infuse normal saline or Ringer’s lactate. This is to restore blood volume and keep the veins open.
• Reassure the woman and family members
• Apply anti-shock garment (ANSG) immediately.
• Monitor BP and urinary output every 15 minutes
• Take history of bleeding
• Assess the woman to identify the cause of bleeding through physical examination.
• Check uterus for contraction (if soft and bulky) as specified above.
• Check the perineum, vagina and cervix for laceration.
• Note if placenta has been delivered, ascertain state of the placenta and membranes
• If placenta is there, examine it for completeness
• If placenta is retained, check is it has separated or still adherent. This is identified through palpating the fungus to see if contracted, if the uterus is contracted, the placenta may have been separated and descended into the vagina
• Deliver the placenta by controlled cord traction.

Specific Treatment

Treatment depends on the identified. Oxytocin is the drug of choice to administer especially for treating haemorrhage due to uterine atony.

Give loading dose of 10IU intramuscularly and 20 – 40 units into infusion to run at the rate of 60 drops per minute maintenance dose of 20IU at 60 drops per unit

Second Drug – Ergometrine if oxytocin is not available but is contraindicated in heart problems.

Third Drug – Misoprostol

General management

• Empty the bladder
• If attempt to remove placenta manually failed, it is placenta accrete
• Allow to absorb and cover the woman with antibiotic
• The obstetrician may decide to carryout hysterectomy.

Rapid Assessment and Resuscitation of the Woman

• Evaluate the woman immediately and ascertain the state of the woman whether she is in shock or if she is not in shock.
• Start immediate resuscitation before you set up IV.
• Ensure airway is open.
• Check breathing and give oxygen by face mask if available.
• Ask your assistant to set up IV-line, Normal Saline or Ringer’s lactate to flow rapidly 1 litre in 30 minutes at least 2 litre of fluid in the first 1 hour. Collect blood for haemoglobin (Hb) estimation, grouping and cross-matching before starting infusion.
• Apply anti-shock garment if available.
• If ASG is not available, raise the woman’s leg to send blood to vital organs.
• Do not lift the foot of the bed as this will cause blood to pool in the uterus.
• Ensure that the bladder is empty as full bladder may present uterine contractions

Therefore, there may be need to catheterize the woman. Monitor vital signs every 15 minutes until patient’s condition stabilizes. If the woman is transferred from another place take history of bleeding

• Note if placenta has been delivered and assess and identify cause of PPH by performing physical examination
• Check uterine contractions
• Do perineal inspection to check for laceration

Note: On no account should a woman in shock be moved before resuscitation and her condition stabilizes.

Treatment of the specific cause

When the cause of bleeding is identified treat the cause. If it is uterine atony that does not respond to oxytocin do bimanual compression of the uterus. If it is retained placenta – do manual removal of placenta

Prevention of Postpartum Haemorrhage

Predicting who will have post-partum haemorrhage is not the best approach; rather taking preventive measures can save a lot of lives. Despite efforts of health workers, PPH may still occur, but quick diagnosis and prompt effective treatment can save life.

Routine preventive actions should be offered to all women from pregnancy till immediate post-partum period as follows:

During Antenatal Care

• Develop a birth preparedness plan: Women should plan to deliver with skilled attendant who can provide intervention to prevent PPH, who can also identify and manage PPH, and referral for additional management.
• Develop emergency referral plan: That includes recognition of danger signs and how to handle if they occur, where to get help, how to get there, how to serve money for transport and emergency care
• Routinely screen: Prevent and treat anaemia during preconception, antenatal and post-partum visits. Counsel woman on nutrition focusing on local available folic acid and iron rich foods and provide iron/folate supplementation during pregnancy.
• Prevent anaemia by addressing major causes of such as malaria, hookworm.
• If a woman does not have access to skilled birth attendants at birth, give her information on signs of labour and to when to access skilled birth attendant as much as they can in order to prevent prolonged/obstructed labour.
• Prevent harmful practices by helping woman and their families recognize harmful traditions during labour (e.g., giving of herbs to increase contractions, giving oxytocin intramuscularly during labour).
• Discuss importance of birth spacing (3 – 5 years) from birth of one baby to the birth of another.
• Take culturally sensitive actions to involve men and encourage understanding about the urgency of labour and need for immediate assistance.

During Labour and Second Stage

• Use a partograph to monitor and manage labour and to quickly detect if progress is not normal.
• Ensure early referral when progress of labour is not normal.
• Encourage the woman to keep her bladder empty.
• Do induction or augmentation of labour only for medical and obstetric reasons.
• Do induction or augmentation of labour only in facilities equipped to perform a caesarean delivery.
• Do not use fundal pressure to assist the birth of the baby.
• Assist the woman in controlled delivery of the baby’s head and shoulders to help prevent tears. Put the fingers of one hand against the baby’s head to maintain flexion, support the perineum and instruct the woman to use breathing and concentration techniques to push or stop pushing as needed.

During Third Stage

• Do the 3 steps of active management of third stage of labour; this is most effective way to prevent PPH.
• Do not use fundal pressure to assist the delivery of the placenta.
• Do not do controlled cord traction without giving oxytocin.
• Do controlled cord traction with counter-traction to support the uterus upward

After Delivery of the Placenta

• Routinely inspect the vulva, vagina, perineum and anus to identify genital lacerations.
• Cervical examination is only recommended when the cause of PPH has not been diagnosed and uterine atony, lower genital lacerations and retained placenta are ruled out.
• Inspect the placenta and membranes
• Evaluate if the uterus is well contracted and massage the uterus regularly after placental delivery to keep the uterus well contracted and firm (at least 15 minutes for the 1st two hour after birth).
• Teach the woman to massage her uterus to keep it firm. Instruct her on how to check her uterus and call for help if her uterus is soft or she noticed increased vaginal bleeding.
• Monitor the woman for vaginal bleeding and uterine hardness every 15 minutes for the 1^st two hours, every 30 minutes during the 3^rd hour and then hour for the next 2 hours.
• Encourage the woman to keep her bladder empty during the immediate post-partum period.
• Plan to do a complete assessment of the woman one and six hours after childbirth.
• Teach the woman and her family about post-partum and newborn danger signs.
• Help the family develop a family emergency referral plan before the woman is discharged from the health care facility.