Postpartum haemorrhage (PPH) is a complication of delivery and the most common cause of maternal death, accounting for about 35% of all maternal deaths worldwide. These deaths have a major impact on the lives and health of the families affected.
PPH is commonly defined as a blood loss of 500 ml or more within 24 hours after birth, while severe PPH is defined as a blood loss of 1000 ml or more within the same timeframe according to World Health Organisation (WHO). A small blood loss that makes the woman haemodynamically unstable is also termed as PPH.
PPH is a major cause of morbidity and mortality with in the first 24 hours following delivery and this is regarded as primary PPH; whereas any excessive bleeding from the birth canal occurring between 24 hours and 12 weeks postnatally (after delivery) is termed as secondary PPH.
In practice, blood loss after delivery is seldom measured and it is not clear whether measuring blood loss improves the care and outcome for the women. In addition, some women may require interventions to manage PPH with less blood loss than others if they are anaemic.
PPH may result from failure of the uterus to contract adequately (atony), genital tract trauma (vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal bleeding disorders. Uterine atony is the most common cause and consequently the leading cause of maternal mortality worldwide.
The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live births versus 12 per 100 000 live births in developed countries. Thus 99% of all maternal deaths occur in developing countries with more than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia. Very small proportion, 1% of maternal deaths occur in the developed world. There are large disparities between countries, but also within countries; maternal deaths are more in low income group and rural areas as compare to high income group and urban areas.
About 830 women die from pregnancy or childbirth-related complications around the world every day. 52% of maternal deaths are attributable to three leading preventable causes-haemorrhage, sepsis, and hypertensive disorders. WHO statistics suggest that 25% of maternal deaths are due to PPH. Postpartum bleeding is the quickest of maternal killers; can kill even a healthy woman within two hours, if not treated.
Incidence of PPH is reported as 2% - 4% after vaginal delivery and 6% after cesarean section; with uterine atony being the cause in about 50% cases. Every year about 14 million women around the world suffer from PPH.
In India sample registration scheme (SRS), during survey of causes of death 1998, reported that PPH was a major cause of maternal mortality and responsible for 30 % of maternal deaths and according to SRS 2001-2003, PPH accounts 38 percent of maternal deaths. Estimates of maternal mortality ratio in India done by Indian Council of Medical Research (ICMR) in 2003 also showed PPH as a leading cause of maternal mortality in study population.
A combination of quality antenatal care, skilled care at birth by active management of third stage of labour, the availability of high quality emergency obstetric care (with trained medical personnel and adequate infrastructure) and improved access to these services are essential to save many maternal lives.
The usual presentation of PPH is one of heavy vaginal bleeding that can quickly lead to signs and symptoms of hypovolemic shock.
Signs of hypovolemic shock resulting from blood loss-
Postpartum haemorrhage (PPH) may result from various reasons such as failure of the uterus to contract adequately (atony), genital tract trauma (vaginal or cervical lacerations), uterine rupture, retained placental tissue, or maternal bleeding disorders.
Causes of primary PPH-
a) Uterine atony is failure of the uterus to contract following delivery. It is the most common cause of maternal mortality worldwide. Atonic bleeding occurs from the placental site when the uterus (myometrial muscles) does not contract and retract properly and thus the blood vessels are not compressed and bleeding is not controlled.
b) Genital trauma: Damage to the genital tract may occur spontaneously or through manipulations used to deliver the baby. Injuries during labour to perineum, vaginal walls, cervix, uterus, episiotomy, caesarean section can also cause PPH. Trauma may occur following very prolonged or vigorous labor, especially if the patient has relative or absolute cephalopelvic disproportion and the uterus has been stimulated with medicines (oxytocin or prostaglandins). Cervical laceration is most commonly associated with forceps delivery. Trauma also may occur following extrauterine or intrauterine manipulation of the fetus.
Uterine rupture is most common in patients with previous cesarean delivery scars. Any uterus that has undergone a procedure resulting in a total or thick or partial disruption of the uterine wall should be considered at risk for rupture in a future pregnancy.
c) Tissue: Uterine contraction and retraction leads to detachment and expulsion of the placenta. Complete detachment and expulsion of the placenta permits continued retraction and optimal occlusion of blood vessels.
Retention of a portion of the placenta and membranes, failure of complete separation of the placenta (placenta accrete) and its variants, placenta previa may cause PPH. The placenta is more likely to be retained at extreme preterm gestations (especially < 24 week) and significant bleeding can occur.
d)Coagulation problems: Women with pre-existing bleeding disorders and women taking therapeutic anticoagulants are at increased risk of PPH. Abnormalities related to bleeding disorder (clotting system) may be preexistent or acquired; such as thrombocytopenia (low platelet count) may be related to preexisting disease called idiopathic thrombocytopenic purpura, or acquired secondary to HELLP syndrome (haemolysis, elevated liver enzymes, and low platelet count)- a complication of preeclampsia, abruptio placentae, disseminated intravascular coagulation (DIC), and sepsis.
An underlying bleeding disorder should be considered in a woman with any of the following: menorrhagia since menarche, family history of bleeding disorders, personal history of notable bruising without known injury, bleeding from the oral cavity or gastrointestinal tract without obvious lesion, or epistaxis (nosebleed) of longer than 10 minutes duration (possibly requiring packing or cautery).
Most cases of PPH have no identifiable risk factors. PPH usually has a single cause, but more than one cause is also possible.
Secondary PPH is the abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally. It is often associated with infection (endometritis).
Factors that prevent women from receiving or seeking care during pregnancy and child birth-
These are the barriers that limit access to quality maternal health services; must be identified and addressed at all levels of the health system to improve maternal health.
Diagnosis of PPH is usually performed by closely observing the pregnant women during child birth and afterwards. After childbirth, blood loss and other clinical parameters should be closely monitored. When estimating the percentage of blood loss, consideration should be given to body weight and the original haemoglobin level (PPH may be aggravated by pre-existing anaemia).
Rapid recognition and diagnosis of PPH is essential to successful management. Resuscitative measures and treatment of the underlying cause must start quickly before sequelae of severe hypovolemia develop.
Clinical examination during third stage of labour -
As the majority of women who experience PPH complications have no identifiable clinical risk factors, it is recommended that active management of the third stage of labour (AMTSL) be offered to all women during childbirth, whenever a skilled provider is assisting with the delivery.
The three components of the active management of third stage of labour (AMTSL):
1. Oxytocic drugs should be offered routinely in the management of the third stage of labour in all women. Prophylactic oxytocic drugs have been found to reduce the risk of PPH by about 60%. If oxytocin is not available, oral misoprostol should be given. Misoprostol can be given by community health worker (ASHA) who may be present in the community during home delivery cases*.
If bleeding is not controlled after use of oxytocin, it is recommended to switch over to the next uterotonic ergot derivatives (methergine) or sublingual misoprostol. (Ergot derivatives (methergine) are contradindicated in hypertensive disorders for the prevention of PPH).
2. Late cord clamping (performed approximately 1 to 3 minutes after birth) is recommended for all births while initiating simultaneously essential new-born care.
3. Controlled cord traction is the recommended method for the removal of the placenta. Uterine massage following the delivery of the placenta is included in AMTSL, where skilled birth attendants are available.
Management of Postpartum haemorrhage-
Initial assessment is performed and basic treatment should be instituted as follows:
Observe factors related to bleeding and determine cause,
(a) If uterine atony is suspected:
If the woman is not responding to the treatment or a treatment cannot be administered at the facility, she should be transferred to a higher-level facility with on-going intravenous uterotonic infusion, legs elevated to improve blood supply to vital organs and keep the woman worm. Accompanying attendant should rub the woman’s abdomen continuously and, if necessary, apply mechanical compression.
If mechanical and pharmacological measures fail to control the haemorrhage, surgical measures are instituted:
(b) If Placenta delivered incomplete
(c) If placenta is not delivered:
If whole placenta still retained
(d) PPH due to lower genital tract trauma: excessive bleeding or shock with contracted uterus-
(e) Uterine rupture or dehiscence: excessive bleeding or shock-
(f) Uterine inversion: uterine fundus not felt abdominally or visible in vagina-
Treat for uterine inversion:
(g) Clotting disorder: bleeding in the absence of above conditions, Treat for clotting disorder as necessary with blood products.
Secondary PPH is the abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally. It is often associated with infection (endometritis) and conventional treatment involves antibiotics and uterotonics.
Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings.
The prevention and treatment of PPH are vital steps towards improving the health care of women during childbirth and the achievement of the Millennium Development Goals.