Postpartum Hemorrhage ( PPH )

Postpartum haemorrhage is defined as excessive bleeding occurring at any time after the birth of the baby upto 6 weeks after delivery in a woman in whom the bleeding amounts to a degree which affects her general condition.

There are two clinical types of postpartum hemorrhage:

Primary postpartum hemorrhage.
Secondary postpartum hemorrhage.

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Primary postpartum hemorrhage: Primary postpartum hemorrhage is defined as bleeding that occurs within 24 hours of the birth of the baby. This is again divided into two type:

Third Stage Haemorrhage: This is primary hemorrhage that occurrs after the delivery of the baby but before the expulsion of the placenta.
True Primary Postpartum Hemorrhage: This is hemorrhage that occurs after the delivery of the placenta at any time within 24 hours of the birth of the baby. The majority of the cases of postpartum hemorrhages fall in this category.

Secondary postpartum haemorrhage: Bleeding that occurs after 24 hours of the delivery of the placenta upto 6 weeks after the delivery is called secondary postpartum hemorrhage. This condition will not be described in this page.

Causes of Primary Postpartum Hemorrhage:

Atonic haemorrhage - 'Atonic' means lack of tone of the muscles or flabby muscles. Failure of the muscles of the uterus to contract properly after the placenta has been delivered is the commonest cause of postpartum hemorrhage. It accounts for about 80% of all cases.
Causes of Atonic Postpartum hemorrhage are:
- Partial or complete retention of the placenta
- When the muscles of the uterus are exhausted after prolonged labour.
- Overdistension of the uterus as in cases of twin pregnancy or hydramnios
- Tumours like fibroids preventing proper contraction of the uterine muscles
- Repeated pregnancies can cause the uterine muscles to become lax and hemorrhage to occur in the later pregnancies.
Traumatic haemorrhage – Bleeding can occur from maternal injuries like cervical, vaginal or perineal tears. While minor tears cause only a minimal bleeding which is easily controlled, deep tears may need to be examined and treated under anesthesia.
Mixed – Postpartum hemorrhage is frequently a mixture of both atonic as well as traumatic hemorrhage. Many of the factors that contribute to the laxity of the uterine muscles are also factors that contribute to injury of the birth canal.
Blood Coagulopathy – Blood coagulopathies like decreased level of platelets in the blood (thrombocytopenia), Factor V Leiden, Von Willebrand's disease are conditions that decrease the ability of the blood to form clots. This can lead to severe hemorrhage.

Management / Treatment of Primary Postpartum Hemorrhage

The main principles of management are:

(a) to prevent further blood loss

(b) to restore proper blood volume.

Treatment depends on whether the bleeding has occured before the placenta has separated from the uterine wall and been delivered or whether the placenta is still in place inside the uterus (Retained Placenta).

In Retained Placenta:

Ergometrine is injected and controlled cord traction is given to try and deliver the placenta, especially in a case of home delivery.
If the above method fails, manual removal of the placenta should be done under general anesthesia in the operating theatre.

Where the placenta has been delivered but bleeding is still present:

Bimanual palpation of the uterus by gripping it with one hand over the abdomen and the other placed in the vagina stimulates the uterus to contract.
Ergometrine is injected.
The cervix, vagina and perineum is examined under proper light for any tears and injuries and if present, they are repaired.
An ultrasound is done to see if the uterus is completely empty of any placental contents. If present, they are removed under GA.
Occasionally, in rare intractable caases, a hysterectomy (removal of the uterus) may be the only option left.
General support of the patient.

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POSTPARTUM HEMORRHAGE

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