A Post Partum Haemorrhage (PPH) is excessive, heavy bleeding after birth (more than 500 millilitres of blood). PPH is divided into two categories, a Primary PPH which occurs within 24 hours of birth, and a Secondary PPH which occurs from 24 hours until 6 weeks after birth. The Australian College of Obstetricians and Gynaecologists (May, 2015) estimate that the incidence of PPH in Australia and New Zealand, is around 5-15% of all births.
Blood loss is expected during the birthing process, when the placenta comes away from the uterine wall and is expelled, usually within 5-30 minutes, following the birth of the baby. The area where the placenta was attached to the uterine wall, becomes a large raw area with blood vessels exposed. The uterus contracts, placing pressure on these vessels, which then collapse and the bleeding settles.
A PPH is diagnosed when the bleeding continues. The most common cause of this excessive bleeding is relaxation of the uterus (an atonic uterus). Other causes may be a tear or damage to the vaginal wall, the cervix or uterus; the placenta not separating or partially separating from the uterine wall; or a portion of the placenta or membranes remaining inside of the uterus. In rare cases a PPH may occur due to a pre-existing blood clotting problem in the mother.
In the past (and certainly in some third world countries today), PPH was the biggest cause of maternal death. PPH is a serious complication of childbirth made more important as it is difficult to predict which woman will have a substantial PPH, but identifying risk groups, is vital. Therefore, there are very clear recommendations for prevention of PPH.
- Antenatally, each woman has a scan to identify where the placenta is situated, as a low lying placenta or a placenta praevia, is associated with an increase in blood loss at delivery.
- All women are tested for iron deficiency anaemia during pregnancy, and offered iron supplements as being anaemic during the birthing process, is an associated risk for PPH.
- Women who have had a previous PPH, are having a multiple birth, are having their fifth or more baby, or who have high blood pressure, are highlighted as potential PPH risks.
However, the majority of women who experience a PPH are not in these antenatal high risk group.
Prevention Of PPH
It is estimated that a 50% reduction in PPH has occurred with the introduction of some simple steps known as “Active management of the third stage” (the delivery of the placenta) for all women during childbirth. These steps are:
- Giving one intramuscular injection of a drug called Oxytocin, which helps the uterus to contract after birth;
- Clamping the cord within a few minutes of birth (delayed cord clamping does not increase the risk of PPH);
- Assisting the delivery of the placenta by using gentle traction.
- If the birth is by Caesarean section, the drug Oxytocin is administered via the drip, and the placenta is delivered through the caesarean wound.
If the bleeding does not settle, immediate measures are instituted by the birth attendant, as this is now called an “obstetric emergency”. Extra staff are called in to the room to do all of the next steps as quickly as possible.
- Intravenous lines will be inserted in both arms in order to replace the fluid loss and a blood sample is collected for analysis
- The uterus is massaged to try and stimulate a contraction
- A catheter will be inserted into the bladder as a full bladder can inhibit the uterus from contracting efficiently
- A larger dose of the contracting agent, Oxytocin, will be administered via intravenous infusion
- The perineum, vagina and cervix will be examined to check for trauma, which may be causing the bleeding, and sutures inserted if this is the cause of the blood loss
- The placenta and membranes will be examined to make sure that they are complete, and that a portion is not left inside the uterus
- The blood pressure and pulse will be checked regularly
- Breastfeeding is encouraged as this evokes a natural release of oxytocin
- Depending on the amount of blood loss and the condition of the mother, a blood transfusion may be initiated.
These steps are usually sufficient to stem the blood flow, and for the post natal period to continue as normal.
Occasionally, the bleeding continues and the woman will need to be transferred to operating theatres as her condition has moved to “a major PPH” where more than 1 litre of blood may have been lost. The partner and infant will stay in the delivery room.
In the operating theatre, the mother is anaesthetised, and an examination of the uterus is performed, through the vagina. Any retained products (a small piece of the placenta or membranes) and clots are removed. The severity of the blood loss may dictate that a balloon catheter is inserted into the uterus. The balloon is inflated with fluid which puts pressure onto the site where the placenta was attached. An injection directly into the uterus, of a drug called Prostaglandin, may be considered. In a small number of cases, abdominal surgery is required, so that direct pressure can be applied to the uterus, to make the uterus contract. If all else fails, a hysterectomy may have to be performed – that is the removal of the uterus. This is an exceptionally rare occurrence.
Once the bleeding is controlled, the mother is cared for either back in the delivery ward or in a high dependency unit where she will be closely observed. If a balloon was inserted into the uterus, it will be removed the following day. Once the mother is stable and the bleeding has subsided, the urinary catheter and the intravenous lines in the arms will be removed. The mother will be transferred to the post natal area for emotional support and routine care. Her length of stay in hospital will be a few days longer than average.
If a secondary PPH occurs, it will generally happen after discharge from hospital. If abnormal heavy bleeding occurs, the woman should contact our office for advice, if during work hours, or the hospital where she delivered, if after hours. Abnormal bleeding is filling a pad every hour or less, with bright blood. A common cause of a secondary PPH is infection and will require a course of antibiotics and possible readmission to hospital. Usually an abdominal ultrasound will be performed to see if the uterus contains retained tissue, a drip will be inserted and the decision made on whether an operation to empty the uterus is required. The baby will be admitted to hospital with the mother, as the length of stay will generally be two days. In the majority of cases, bleeding will settle with simple measures.
It is important to remember that bleeding is normal when you have a baby. The majority of women will not have a Post Partum Haemorrhage. The bleeding may increase with activity in the first few weeks, and then settle. This is normal.
Read more on changes to the body after birthing: