Severe bleeding after childbirth, or postpartum hemorrhage (PPH), is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following cesarean delivery. A loss of these amounts within 24 hours of delivery is termed primary PPH, while losses that occur after 24 hours are termed secondary PPH (World Health Organization 2012).
PPH is a major complication of the third stage of labor—the period following delivery of the newborn until the completed delivery of the placenta—and is the leading cause of maternal morbidity and mortality, contributing to approximately 25–30% of maternal deaths worldwide. Globally, about 14 million women suffer from PPH, and approximately 2% die annually, with 99% of these deaths occurring in developing countries with limited healthcare resources (Say et al. 2014).
PPH is also associated with obesity. In a study by Blomberg, the risk of atonic uterine hemorrhage increased rapidly with increasing body mass index (Blomberg 2011). Additionally, Hanley et al. reported that exposure to serotonin reuptake inhibitors (SSRIs) in late pregnancy was associated with a 1.6 to 1.9-fold increased risk of PPH (Hanley et al. 2015).
Causes of PPH
PPH has several potential causes, with uterine atony—failure of the uterus to contract and retract following delivery—being the most common by far (Mousa and Alfirevic 2007). Other causes include retained placenta, genital tract lacerations, and coagulation disorders (thrombin). Risk factors contributing to high maternal morbidity and mortality from PPH include inadequate blood banks and intensive care units, anemia, poor nutritional status, high parity, home deliveries, and delays in accessing and receiving prompt care at health facilities (Carroli et al. 2008).
Complications of PPH
Immediate complications include shock, blood transfusion reactions, embolism, disseminated intravascular coagulopathy (DIC), and hysterectomy, which can lead to permanent loss of fertility.
Late complications include septicemia, Sheehan’s syndrome, multiple organ failure, acute renal failure, acute respiratory distress syndrome (ARDS), and maternal death (Knight et al. 2009).
Prevention of Primary PPH
- Community awareness education to recognize the importance of PPH as a killer and referrals should be prompt
- Encourage antenatal care and hospital deliveries
- Family planning-increase child spacing and also iron stores.
- Women- use of Long-lasting insecticide Treated net and intermittent preventive therapy for malaria (IPT) to prevent anaemia and malaria.
- Improvement in the general nutrition
- Women empowerment and education- better health seeking behaviour
- Better trained care givers- skilled birth attendant
Management of PPH
High-quality evidence indicates that active management of the third stage of labor reduces the incidence and severity of PPH. Active management consists of:
– Uterotonic administration, preferably oxytocin, immediately after delivery.
– Early cord clamping and cutting.
– Gentle cord traction with uterine countertraction when the uterus is contracted (Brandt-Andrews maneuver) (Begley et al. 2011).
Treatment of patients with PPH has 2 major components (1) resuscitation and management of obstetric hemorrhage and possibly hypovolemic shock. (2) identification and management of hemorrhage.
Blood Transfusion
Blood transfusion should be ordered if blood loss exceeds 2000 mL or if the patient’s clinical condition indicates developing shock despite aggressive fluid resuscitation (World Health Organization 2012).
Works Cited
Begley, Cecily M., et al. “Active versus Expectant Management for Women in the Third Stage of Labour.” Cochrane Database of Systematic Reviews, no. 7, 2011, doi:10.1002/14651858.CD007412.pub3.
Blomberg, Marie. “Maternal Obesity and Risk of Postpartum Hemorrhage.” Obstetrics & Gynecology, vol. 118, no. 3, 2011, pp. 561–568.
Carroli, Guillermo, et al. “WHO Systematic Review of the Management of the Third Stage of Labour with Oxytocin.” BJOG: An International Journal of Obstetrics & Gynaecology, vol. 115, no. 5, 2008, pp. 603–612.
Hanley, Gillian E., et al. “Selective Serotonin Reuptake Inhibitors and the Risk of Postpartum Hemorrhage: A Population-Based Cohort Study.” British Journal of Clinical Pharmacology, vol. 79, no. 1, 2015, pp. 126–134.
Knight, Marian, et al. “Trends in Postpartum Hemorrhage in High Resource Countries: A Review and Recommendations from the International Postpartum Hemorrhage Collaborative Group.” BMC Pregnancy and Childbirth, vol. 9, no. 1, 2009, p. 55.
Mousa, Haitham A., and Zarko Alfirevic. “Treatment for Primary Postpartum Hemorrhage.” Cochrane Database of Systematic Reviews, no. 1, 2007, doi:10.1002/14651858.CD003249.pub2.
Say, Lale, et al. “Global Causes of Maternal Death: A WHO Systematic Analysis.” The Lancet Global Health, vol. 2, no. 6, 2014, pp. e323–e333.
World Health Organization. WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. WHO, 2012.
