Postpartum haemorrhage

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.

References-

www.who.int/maternal_child_adolescent/documents/MPSProgressReport

www.who.int/mediacentre/factsheets/fs348/en/

www.who.int/medicines/areas/priority_medicines/Ch6_

emedicine.medscape.com/article/275038-overview#a5

www.ncbi.nlm.nih.gov/pmc/articles/PMC3688110/

planningcommission.nic.in/aboutus/committee/strgrp/stgp_

www.icmr.nic.in/final/Final%20Pilot%20Report.pdf

file.scirp.org/pdf/OJOG_2015092116115550.pdf

www.unmillenniumproject.org/documents/TheLancetChildHealthMaternalHealth.pdf

www.who.int/pmnch/media/events/2015/gs_2016_30.pdf

nrhm.gov.in/images/pdf/programmes/maternal-health/guidelines/

The usual presentation of PPH is one of heavy vaginal bleeding that can quickly lead to signs and symptoms of hypovolemic shock.

  • Blood loss is usually visible at the introitus, and this is especially seen when the placenta has delivered. If the placenta remains inside the uterus, then a significant amount of blood can be retained in the uterus behind a partially separated placenta, the membranes, or both.
  • Even after placental delivery, blood may collect in an atonic uterus. For this reason, the uterine size and tone should be monitored throughout the delivery and following delivery of the placenta. This is done by gently palpating the uterine fundus.
  • If the cause of bleeding is not uterine atony, then blood loss may be slower and clinical signs and symptoms of hypovolemia may develop over a longer time period. Bleeding from trauma may be concealed in the form of hematomas of the retroperitoneum, broad ligament or lower genital tract, or abdominal cavity.

Signs of hypovolemic shock resulting from blood loss-

  • Fall in blood pressure (BP), (BP may be normal initially)
  • Palpitations, tachycardia, dizziness
  • Weakness, sweating
  • Restlessness, pallor,
  • Oliguria (reduced urine volume)

Reference-

emedicine.medscape.com/article/275038-overview#a10

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.

  • Any condition that interferes with uterine contraction, such as a retained placenta, remnants of placental tissue, membranes and blood clot will predispose to atonic bleeding. Full bladder, antepartum haemorrhage due to placenta praevia (low lying attachment of placenta) or placental abruption (separation of placenta from uterus prior to delivery) may also cause PPH.
  • Overstretched uterus as seen in high parity, multiple pregnancy, polyhydramnios (Increased amount of amniotic fluid), large baby, fibroids may be the risk factors for atonic PPH.
  • Poor myometrial contraction can result from fatigue due to prolonged labor or rapid forceful labor, especially if stimulated. It can also result from the inhibition of contractions by drugs (such as halogenated anesthetic agents, nitrates, nonsteroidal anti-inflammatory drugs, magnesium sulfate, beta-sympathomimetics, and nifedipine). Anaemia is also a risk factor for PPH. 
  • Intrauterine death with fetus retained in uterus for three to four weeks, severe pre-eclampsia and eclampsia may also lead to PPH.

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-

  • Poverty
  • Distance
  • Lack of information
  • Inadequate services
  • Cultural practices

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.

References-

www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/

www.who.int/mediacentre/factsheets/fs348/en/

emedicine.medscape.com/article/275038-overview#a7

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).

  • Blood volume depends on the body weight. Approximate blood volume (in litres) equals body weight in kilograms divided by 12.
  • Visually estimating the amount of blood loss may lead to underestimation. There is not enough evidence though to recommend the measurement of blood loss over clinical estimation.
  • Blood collection drapes for vaginal deliveries and weighing swabs are more accurate than visual blood loss estimation.
  • Participating in clinical reconstructions may encourage early diagnosis and prompt treatment of postpartum haemorrhage.
  • Written and pictorial guidelines may help staff working in labour wards to estimate blood loss.

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.

Investigations-

  • Complete blood count for diagnosis of anaemia during antenatal period and labour.
  • Blood typing and antibody screening tests during antenatal period.  
  • Cross matching of blood for a patient at high risk of PPH such as previous severe PPH, placenta previa, possible placenta accreta, multiple previous cesarean deliveries, known coagulation disorders, or severe thrombocytopenia. (Notifying the blood bank of the possible need for additional blood products in short order).
  • Coagulation studies.
  • Antenatal ultrasound for detecting high-risk patients with predisposing factors for PPH,
  • All women who have had a caesarean section previously must have their placental site determined by ultrasound near term.

Clinical examination during third stage of labour -

  • Assessment of uterine tone and size
  • Inspection of placenta if delivered
  • Manual exploration of uterus for placenta and membranes
  • Palpation and inspection for hematomas
  • Inspection of cervix and vagina for any injury 
  • Additional investigations for diagnosis of secondary PPH include:
    • High and low vaginal swabs
    • Blood cultures if pyrexia (fever)
    • Full blood count
    • C-reactive protein
    • Pelvic ultrasound that might help to exclude the presence of retained products of conception

References-

emedicine.medscape.com/article/275038-overview#a10

www.gfmer.ch/omphi/pph/pdf/pph.pdf

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:

  1. Call for help
  2. Assess airway, breathing, circulation (ABC)
  3. Provide supplementary oxygen
  4. Obtain intravenous line
  5. Start fluid replacement with intravenous crystalloid fluid
  6. Monitor blood pressure, pulse and respiration
  7. Catheterize bladder and monitor urinary output
  8. Assess need for blood transfusion
  9. Start intravenous oxytocin infusion
  10. Order laboratory tests-complete blood count, coagulation screen, blood grouping and cross-match

Observe factors related to bleeding and determine cause,

(a) If uterine atony is suspected:

  • Uterine massage; ((Uterine packing is not recommended for the treatment of PPH due to uterine atony after vaginal delivery);
  • bimanual uterine compression;
  • external aortic compression; and
  • balloon or condom tamponade.

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:

  • Compression sutures
  • Bilateral ligation of uterine arteries
  • Bilateral ligation of internal iliac (hypogastric) arteries
  • Hysterectomy

(b) If Placenta delivered incomplete

  • Oxytocin
  • Manual exploration to remove fragments
  • Gentle curettage or aspiration
  • If bleeding continues, manage as uterine atony.

(c) If placenta is not delivered:

  • Additional oxytocin in combination with controlled cord traction

If whole placenta still retained

  • Manual removal with prophylactic antibiotics

(d) PPH due to lower genital tract trauma: excessive bleeding or shock with contracted uterus-

  • Look for lower genital tract trauma with repair of tears; and evacuation and repair of haematoma.
  • If bleeding continues administer tranexamic acid.

(e) Uterine rupture or dehiscence: excessive bleeding or shock-

  • Treat for uterine rupture or dehiscence with laparotomy for primary repair of uterus and Hysterectomy if repair fails.
  • If bleeding continues administer tranexamic acid.

(f) Uterine inversion: uterine fundus not felt abdominally or visible in vagina-

Treat for uterine inversion: 

  • Immediate manual replacement
  • Hydrostatic correction
  • Manual reverse inversion (use general anaesthesia or wait for effect of any uterotonic to wear off)
  • If treatment is not successful, laparotomy is advised to correct inversion.
  • If laparotomy correction is not successful then hysterectomy is performed.

(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.

References-

apps.who.int/iris/bitstream/10665/44171/1/9789241598514_eng.pdf

www.gfmer.ch/omphi/pph/pdf/pph.pdf

* http://nrhm.gov.in/images/pdf/programmes/maternal-health/guidelines

 

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.

  • Women and adolescents are the most powerful agents for improving their own health and achieving prosperous and sustainable societies. All adolescents should be given health education to realize their rights to health, well-being, education and full and equal participation in society. Promote health education to couples to make them understand the importance of antenatal checkups, hospital deliveries and small family norms with expectation of supportive attitude and behavior from male partners.
  • During pregnancy, each pregnant woman should be investigated for anaemia and treated appropriately as this may reduce the occurrence and morbidity associated with PPH.
  • At the household level, ASHA/ANM (accredited social health activists/auxiliary nurse midwife) sensitizes the key decision makers and pregnant women for timely access to health services through pre-identified transport facility. Risk factors for PPH may present antenatally or intrapartum; hence birth preparedness and complication readiness (BPCR) plan must be prepared and may be modified as and when risk factors arise.
  • Pregnant women and her relatives should be encouraged for institutional delivery. Women with known risk factors for PPH should only be delivered in a hospital with a blood bank on site. In cases where, for some reason, the woman is unable to access the health facility at the time of delivery and home delivery is imminent; the ANM or any other skilled birth attendant should conduct this delivery. In home deliveries where ANMs cannot attend to the women, ASHAs have been allowed to undertake advance distribution of misoprostol to pregnant women in the 8th month of pregnancy, for self-administration just after childbirth, for prevention of PPH*.
  • PPH need to be reduced by strengthening peripheral delivery facilities, active third stage management and early referral. Though the institutional deliveries are increasing in the country; the capacity of the system to address obstetric emergencies and resultant life threatening complications needs to be strengthened.
  • Ministry of Health and Family Welfare, Government of India has released guidelines as “Guidance Note on Prevention and Management of Postpartum haemorrhage”* and promoted the concept of Obstetric High Dependency Units (HDU) and Obstetric Intensive Care Units (ICU) ** in the country. It is suggested that all District Hospitals should have an Obstetric HDU and all the Medical Colleges should have both an obstetric HDU and an obstetric ICU (or ICU with dedicated obstetric beds). Subsequently based on the availability of resources, the states can set up obstetric HDUs in high delivery load facilities such as community health centers and block primary health centers (CHCs and block PHCs).

References-

www.who.int/pmnch/media/events/2015/gs_2016_30.pdf

www.who.int/maternal_child_adolescent/documents/MPSProgressReport09-FINAL.pdf

www.who.int/maternal_child_adolescent/documents/MPSProgressReport09-FINAL.pdf

www.who.int/whr/2005/chapter4/en/index1.html 

* nrhm.gov.in/images/pdf/programmes/maternal-health/guidelines/Guidance_Note_on_Prevention_&_Management_of_Postpartum_Haemorrhage.pdf

** nrhm.gov.in/images/pdf/programmes/maternal-health/guidelines/Guidelines_for_Obstetric_HDU_and_ICU.pdf

  • PUBLISHED DATE : Mar 16, 2017
  • PUBLISHED BY : Zahid
  • CREATED / VALIDATED BY : Dr. Aruna Rastogi
  • LAST UPDATED ON : Mar 16, 2017

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