According to the World Health Organization’s report on December 20, 2018, around 14 million women across the whole world suffer from postpartum bleeding every year. Postpartum hemorrhage is the discharge of excessive vaginal blood more than 500ml after childbirth. As we know that a majority of the women in the world are anemic, even a small amount of blood loss can be life-threatening for them. This heavy bleeding during the postpartum period can put a mother’s life at a greater risk.
While most deliveries are done without suffering from PPH, research published by American Family Physician shows that approximately 3 to 5% of obstetric patients experience postpartum hemorrhage after delivery. The average spontaneous vaginal birth usually causes bleeding ranging from 300ml to 500ml. While on the other hand during cesarean delivery, the average loss of blood increases between 800ml to 1000ml.
Most of the time, this postpartum bleeding occurs soon after giving birth but it can also happen later. But the risk of hemorrhage is highest in the first 24 hours. So, let us provide you with the knowledge related to how to prevent postpartum hemorrhage, its causes, symptoms, treatment, and each and everything, the moms-to-be and the new moms need to know.
Postpartum Hemorrhage Types
Postpartum hemorrhage is classified into two main types.
- Primary / Early postpartum hemorrhage.
- Secondary / Late postpartum hemorrhage.
Primary postpartum hemorrhage can be defined as the loss of more than 500ml of blood from the maternal genital tract within 24 hours of the birth of the baby. Over 99% of the postpartum hemorrhage cases are Early PPH.
Secondary or late postpartum hemorrhage can be defined as excessive bleeding from the birth canal occurring between 24 hours to 6 weeks after childbirth. 2% of the postnatal women across the developed countries are admitted to the hospital with PPH.
Postpartum hemorrhage is further divided into major PPH and minor PPH. Minor postpartum bleeding ranges from 500ml to 1000ml. And major PPH ranges from 1000ml to 2000ml loss of blood. This major is subdivided into moderate PPH and severe PPH. Moderate ranges from 1000ml to 2000ml while severe postpartum hemorrhage is the one in which blood loss exceeds more than 2000ml.
Risk Factors of Postpartum Hemorrhage
Postpartum hemorrhage occurs in women with or without risk factors. However, 20% of the postpartum bleeding occurs in women without risk factors. So, gynecologists should be prepared to face and cope with this situation with every delivery.
Those women are at higher risk of postpartum hemorrhage who are carrying multiple pregnancies at a time (twins or triplets, etc) or a very large only baby, and the woman who has experienced multiple pregnancies before.
The factors that increase the risk of postpartum hemorrhage are listed below:
- Antepartum hemorrhage
- Maternal obesity
- Maternal anemia
- General anesthesia
- Fetal macrosomia
- Multifetal gestation
- polyhydramnios (excess amniotic fluid)
- Augmented labor
If the mother has any of the above risk factors, the doctor will check on her carefully and take precautionary measures to prevent postpartum hemorrhage in the next 24 to 48 hours after delivery.
Causes of Postpartum Hemorrhage
Once the baby comes out of the mother’s body, the uterine contraction usually occurs for placental separation and tends to push it out. After the placenta is delivered, these muscle contractions help to control bleeding by exerting pressure on the blood vessels surrounding the placenta. If the uterus does not exhibit these contractions, resulting in postpartum bleeding.
Probably, the most common cause of postpartum hemorrhage is uterine atony, which means that during childbirth, the smooth muscles of the uterus do not contract enough during labor to control bleeding at the placental site. Some women are at higher risk for PPH than others.
Several other factors that can be associated with postpartum hemorrhage include:
- Multiple fetuses.
- Excess amniotic fluid.
- A large fetus.
- PPH in the previous delivery.
- Uterine inversion.
- Uterine rupture.
- Retained tissue or invasive placenta.
- Prolonged labor.
- Clotting disorders.
- Retained placenta.
- Placenta previa.
- Cervical, Vaginal, and perineal lacerations.
- Placental abruption (early detachment of the placenta from the uterus).
- Retained placental fragments (possibly including the placenta accreta).
Among all of the above causes of PPH mentioned above, the rupture of the uterus is the most terrifying cause that can absolutely lead to maternal death. Excessive and rapid blood loss can lead to a rapid drop in maternal blood pressure which can lead to shock or even death.
Signs And Symptoms of Postpartum Hemorrhage
Mostly, cases of postpartum hemorrhage happen during delivery or immediately after childbirth. The vital signs and symptoms of postpartum hemorrhage are described below. However, every pregnant woman can have different symptoms and suffer differently.
- Uncontrolled bleeding.
- Feeling lightheaded, dizzy or you may faint.
- Increased heart rate.
- Belly pain.
- Blurry vision.
- Extreme fatigue.
- Decreased blood pressure.
- Decrease in the red blood cell count (hematocrit).
- If bleeding is happening due to hematoma, swelling and pain occur in the tissues of the vaginal and perineal area.
The symptoms of PPH described above may appear or resemble other medical issues. So, see your doctor if you observe any of these after giving birth.
Measures To Prevent Postpartum Hemorrhage
Although postpartum hemorrhage is common, birthing women receive special care to prevent hemorrhage after the birth of the baby. Every woman needs to know what puts them at risk for postpartum hemorrhage after delivery. They should have the knowledge to handle this situation and call an emergency at the birth time because early prevention can make them prevent excessive blood loss.
Here, we have come up with the most effective strategies for the management of postpartum hemorrhage that will be helpful for patient safety. So, let’s go ahead.
Active Management of The Third Stage of Labor (AMTSL)
Active management of the third stage of labor should routinely be done in order to avoid the incident. AMTSL involves prophylactic uterotonic treatment, early cord clamping, and usually controlled cord traction to deliver the placenta and it shortens the third stage of labor without significantly increasing the risk of retained placenta. Additionally, AMTSL includes injecting uterotonic drugs soon after the delivery of the anterior shoulder.
You0 know what, active management as compared to expectant management which simply involves the spontaneous removal of the placenta with the assistance of nipple stimulation or gravity, reduces the incidence of postpartum hemorrhage by 68%. In addition, the appropriate management of the third phase of labor reduces the risk of maternal postpartum hemoglobin levels lower than 90 g per L and the need for manual placenta removal.
Use of Uterotonic Drugs
Several birth centers and hospitals immediately prefer to use Pitocin injection to make the uterus contract and to ensure the quick and complete removal of the placenta for patient safety while others prefer to wait and see if there is a bleeding issue. However, the most common uterotonic drugs used to lower the obstetric bleeding risk are Oxytocin, Misoprostol, Carbotene, Ergometrine, or the combination of all these drugs. The use of any of the above uterotonics immediately after the delivery of a newborn is one of the most important interventions to prevent PPH.
Among the multiple uterotonic options available, The World Health Organization has recommended the usage of oxytocin (10 IU/ IM/ IV) for the prevention of PPH for all deliveries.
If oxytocin is not available or if its quality can not be compromised, the use of other uterotonics to decrease blood loss is suitable. Misoprostol along with oxytocin causes uterine contractions and has been used for a longer period to treat uterine atony and reduce blood loss during childbirth. This uterotonic drug is inexpensive and does not require any syringes.
To reduce the need for therapeutic uterotonics in elective cesarean section, an intravenous bolus of 100-micron Carbetocin is used over 1 minute instead of continual oxytocin infusion for preventing the risk of postpartum hemorrhage.
Ergonovine may be used to treat uterine atony but it is considered as a second choice to oxytocin. It is because it offers a greater risk due to fewer adverse effects and the need for manual removal of the placenta. Ergonovine is contraindicated in hypertension patients.
Routine episiotomy needs to be avoided to reduce excessive blood loss and the risk of anal laceration. The uterotonic drugs mentioned above for preventing postpartum hemorrhage can be administrated in all the women going through vaginal birth or cesarean delivery. However, skilled health personnel trained is required to administer all the injectable uterotonics except for Misoprostol.
Delayed Cord Clamping
In premature infants who might be suffering from anemia, delaying cord clamping for approximately 60 seconds can result in increasing iron stores and prevent newborns safe from anemia. This delay is not done to enhance neonatal morbidity or maternal blood loss.
To ensure your bladder is completely empty after the delivery, can also avoid postpartum hemorrhage. American Academy of Pediatrics recommends that new moms breastfeed the newborn immediately after delivery as it triggers the release of the hormone, oxytocin which is helpful in the contraction of the uterus and quickly expelling the placenta out of the mother’s body. In addition, postpartum uterine massage is performed too to expel the clots of blood and check the uterine tone to ensure that it is clamping down to prevent excessive blood flow in the postpartum period.
How is PPH Tested For And Treated?
Based on the symptoms of postpartum hemorrhage, you need to visit your fam physician for a prompt diagnosis. Laboratory tests often help with diagnosis and the tests which are usually performed for PPH diagnosis are:
- Blood loss estimation
- Clotting factors in the maternal blood
- Pulse rate
- Measurement of Blood pressure
- Hematocrit (RBC count)
The estimation of blood loss can be made by weighing the sponges used to absorb the blood or by counting the number of saturated swabs. Moreover, one milliliter of blood weighs approximately 1 gram.
Before starting the treatment of postpartum hemorrhage, the doctor will first determine the overall women’s health. Then the specific treatment of PPH is determined by the doctor on the basis of the patient’s:
- Medical history.
- Pregnancy state.
- Overall health.
- Point of view of the patient.
- Expectations for the course of the condition.
- The tolerance of the patient’s body for specific drugs, therapies, and procedures.
If your body is ready to take the treatment procedure, your doctor starts working on it. The goal of providing this postpartum bleeding treatment is to stop excessive bleeding from the vaginal site. To treat PPH, the following options are available:
- Medicines for the uterus to contract.
- Uterine massage.
- A Foley catheter is used to compress any bleeding in the uterus.
- The uterus is often filled with sponges and sterile supplies to control blood from the bleeding vessels.
- Removal of pieces of placenta that remain in the uterus.
- Laparotomy– A surgery for finding the bleeding cause by opening the abdomen.
- Hysterectomy– If bleeding does not stop with all methods, the last resort for doctors is to operate on the mother and remove the uterus from the body.
- Uterine compression sutures are often used to try to remove the bleeding blood vessels.
In order to avoid the shock during postpartum bleeding, use intravenous blood, blood products, and fluids to treat postpartum hemorrhage. Moreover, blood replacement for the lost blood from the blood bank is also necessary to prevent maternal death. The mother may also receive oxygen by a mask.
Postpartum hemorrhage can be serious, although it may happen in only 5% of worldwide births. It causes a quarter of maternal deaths worldwide. However, preventing the causes of this serious life-taking curse can make you and your baby safe. If you observe any of its symptoms, don’t ignore it. Quickly diagnosing and treating postpartum hemorrhage at the right time can often lead to full recovery.
An important consideration is that the mother should continue her relaxing and breathing techniques, which she used during labor, while the placenta is being delivered. Keep in mind, don’t tense your abdominal muscles. Otherwise, it can lead to PPH and make the situation worse.
In addition, health professionals should disseminate knowledge on how to prevent postpartum hemorrhage for maternal safety in the rural areas where people are unaware of how to deal with this situation and save maternal life.