|Classification and external resources|
|Patient UK||Postpartum hemorrhage|
Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate. As more blood is lost the women may feel cold, their blood pressure may drop, and they may become restless or unconscious. The condition can occur up to six weeks following delivery.
The most common cause is poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who: already have a low amount of red blood, are Asian, with bigger or more than one baby, are obese or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, and those who have an episiotomy.
Prevention involves decreasing known risk factors including if possible procedures associated with the condition and giving the medication oxytocin to stimulate the uterus to contract shortly after the baby is born. Misoprostol may be used instead of oxytocin in resource poor settings. Treatments may include: intravenous fluids, blood transfusions, and the medication ergotamine to cause further uterine contraction. Efforts to compress the uterus using the hands may be effective if other treatments do not work. The aorta may also be compressed by pressing on the abdomen. The World Health Organization has recommended non-pneumatic anti-shock garment to help until other measures such as surgery can be carried out.
In the developing world about 1.2% of deliveries are associated with PPH and when PPH occurred about 3% of women died. Globally it results in 86,000 deaths per year making it the leading cause of death during pregnancy. About 0.4 women per 100,000 deliveries die from PPH in the United Kingdom while about 150 women per 100,000 deliveries die in sub-Saharan Africa. Rates of death have decreased substantially since at least the late 1800s in the United Kingdom.
Depending on the definition in question, postpartum hemorrhage is defined as more than 500ml or 1000ml of blood loss in the first 24 hours following delivery.
Signs and symptoms
Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate. As more blood is lost the women may feel cold, their blood pressure may drop, and they may become unconscious.
- Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony. Uterine atony is the most common cause of postpartum hemorrhage.
- Trauma: Injury to the birth canal which includes the uterus,cervix,vagina and the Perineum which can happen when the delivery is not monitored properly.The bleeding is substantial as all these organs become more vascular during pregnancy.
- Tissue: retention of tissue from the placenta or fetus may lead to bleeding.
- Thrombin: a bleeding disorder occurs when there is a failure of clotting, such as with diseases known as coagulopathies.
Oxytocin is typically used right after the delivery of the baby to prevent PPH. Misoprostol may be used in areas where oxytocin is not available. Early clamping of the umbilical cord does not decrease risks and may cause anemia in the baby, thus is usually not recommended.
The World Health Organization started recommending the use of a device called the nonpneumatic anti-shock garment (NASG) in 2012 for use in delivery activities outside of a hospital setting, the aim being to reverse shock in a mother suffering from obstetrical hemorrhage long enough to reach a hospital.
A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative. It describes 4 stages of obstetrical hemorrhage after childbirth and its application reduces maternal mortality.
- Stage 0: normal - treated with fundal massage and oxytocin.
- Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red blood cells.
- Stage 2: bleeding continues - check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy.
- Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.
A Cochrane review suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) during the third stage of labour reduces severe bleeding and anemia. However, the review also found that active management increased the mother's blood pressure, nausea, vomiting, and pain. In the active management group more women returned to hospital with bleeding after discharge, and there was also a reduction in birthweight due to infants having a lower blood volume. Another Cochrane review looking at the timing of the giving oxytocin as part of the active management found similar benefits with giving it before or after the expulsion of the placenta.
Methods of measuring blood loss associated with childbirth vary, complicating comparison of prevalence rates. A systematic review reported the highest rates of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with an overall rate globally of 10.8%. The rate in both Europe and North America was around 13%. The rate is higher for multiple pregnancies (32.4% compared with 10.6% for singletons), and for first-time mothers (12.9% compared with 10.0% for women in subsequent pregnancies). The overall rate of severe PPH (>1000 ml) was much lower at an overall rate of 2.8%, again with the highest rate in Africa (5.1%).
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-  CMQCC guidelines, accessed August 10, 2009
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- WHO recommendations for the prevention and treatment of postpartum haemorrhage.. Geneva: World Health Organization. 2012. ISBN 9789241548502.
- Postpartum hemorrhage and the B-Lynch technique