Postpartum haemorrhage (PPH) is a condition where severe vaginal bleeding occurs after childbirth. It is an obstetrician's nightmare considering that it contributes to nearly 35% of all maternal deaths in India and is a leading cause of maternal death worldwide. The majority of PPH occurs in the first 24 hours of delivery and complicates approximately 2% of childbirth. Severe PPH ( blood loss of 1000 ml or more within the first 24hrs after delivery) results in long-term morbidity and mortality.
Several Factors That Lead To Postpartum Haemorrhage
According to Dr Neha Gupta, Senior Consultant, Obstetrics & Gynecology Fortis Hospital, Noida, following are the factors that lead to PPH.
The biggest risk factor for PPH is atony —the inability of muscles of the uterus to stay in a contracted state post-placental delivery. This leads to excessive blood loss from the organ, which is highly vascular at the time of delivery.
The retained placentas that do not completely emerge post-delivery can prompt haemorrhage.
Lacerations from delivery, especially with vacuum or forceps use, require a suture. Traumatic lacerations may also occur during cesarean sections, especially when done after prolonged labour.
Maternal coagulation disorders can make you vulnerable to losing excess blood as clot formation is hampered.
Placental implantation abnormalities, where placental tissue invades deep into muscles of the uterus, especially after multiple cesarean deliveries, may provoke haemorrhage.
This may require a hysterectomy or uterine artery embolization. However, if the placental invasion is not too deep, the provider can preserve the uterus.
Risk Factors That Can Cause Postpartum Haemorrhage
Good antenatal care is important, with regular visits ensuring the correction of anaemia with prophylactic Iron- folic acid tablets. Identification and control of risk factors should be made. Delivery should be planned at a place where necessary expertise and resources are present to conduct the delivery safely. Risk factors are as follows.
1. Multiple pregnancies ( twins)
2. Polyhydramnios ( excess amniotic fluid)
3. Pre-eclampsia ( maternal hypertension)
4. Antepartum haemorrhage (low-placed placenta or placental separation before delivery)
5. Fibroids in Pregnancy
6. Anemia- It makes the mother more vulnerable to adverse outcomes with minimal bleeding during childbirth.
Unfortunately, it is impossible to predict which mother would have PPH. Treatment options are as follows:
WHO recommends active management of the third stage of labour which is universally practised for all births using Oxytocin (10 IU, IV/IM). According to the doctor, if oxytocin is not available, oral misoprostol (600 µg) or (if appropriate, ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine) should be used.
Addressing The Cause Of Bleeding
Treatment of PPH is done as per guidelines and depends on addressing the cause of bleeding. The atonic uterus is managed medically using uterotonics drugs to contract uterine muscles like oxytocin, methergine, and prostaglandins. Most maternity units follow protocols where resident doctors, staff nurses and senior obstetricians together attend this emergency.
Balloon tamponade, bimanual compression of the uterus, and vacuum retraction are used as per availability, requirement and expertise. Timely surgical intervention by stepwise devascularization or obstetrical hysterectomy is done by competent doctors if the need arises. Availability of blood, transport, and referral facilities to an equipped tertiary care centre may help save the lives of mothers.