Postpartum hemorrhage (PPH) is the most common form of major obstetric haemorrhage. The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby. About 4 percent of women have postpartum hemorrhage and it is more likely with a cesarean birth. Hemorrhage may occur before or after the placenta is delivered. The average amount of blood loss after the birth of a single baby in vaginal delivery is about 500 ml (or about a half of a quart). The average amount of blood loss for a cesarean birth is approximately 1,000 ml (or one quart). Most postpartum hemorrhage occurs right after delivery, but it can occur later as well.
Postpartum hemorrhage can be divided into 2 types:
• Early postpartum hemorrhage, which occurs within 24 hours of delivery.
•Late postpartum hemorrhage, which occurs 24 hours to 6 weeks after delivery.
Most cases of postpartum hemorrhage, greater than 99%, are early postpartum hemorrhage
• uncontrolled bleeding
• swelling and pain in tissues in the vaginal and perineal area
• decreased blood pressure
• increased heart rate
• decrease in the red blood cell count (hematocrit value)
The most common cause of postpartum hemorrhage is Uterine atony.
Once a baby is delivered, the uterus normally contracts and pushes out the placenta. After the placenta is delivered, these contractions help put pressure on the bleeding vessels in the area where the placenta was attached. If the uterus does not contract strongly enough, these blood vessels bleed freely. This is the most common cause of postpartum hemorrhage. If small pieces of the placenta stay attached, bleeding is also likely.
Postpartum hemorrhage may also be caused by:
• Tear in a blood vessel in the uterus
• Tear in the cervix or tissues of the vagina
• Bleeding into a hidden tissue area or space in the pelvis. This mass of blood is called a hematoma. It is usually in the vulva or vagina.
• Blood clotting disorders
• Placenta problems
Risk Factors –
Some women are at greater risk for postpartum hemorrhage than others. Conditions that may increase the risk include:
• Placenta previa. This is when the placenta covers or is near the opening of the cervix.
• Placental abruption. This is the early detachment of the placenta from the uterus.
• Overdistended uterus. This is when the uterus is larger than normal because of too much amniotic fluid or a large baby.
• High blood pressure disorders of pregnancy
• Prolonged labor
• Having many previous births
• Multiple-baby pregnancy
• Use of forceps or vacuum-assisted delivery
Losing lots of blood quickly can cause a severe drop in your blood pressure. This may lead to shock and death if not treated.
Healthcare provider will review your health history and do a physical exam. Lab tests often help with the diagnosis.
Other tests may include:
• Estimate of how much blood you have lost
• Measuring pulse and blood pressure
• Red blood cell count
• Clotting factors in the blood
The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as quickly as possible.
Treatment for postpartum hemorrhage may include:
• medication (to stimulate uterine contractions uterotonics e.g. oxytocin, prostaglandins, methylergonovine)
• manual massage of the uterus (to stimulate contractions).
• examination of the uterus and other pelvic tissues.
• removal of placental pieces that remain in the uterus.
• packing the uterus with sponges and sterile materials (to compress the bleeding area in the uterus).
• tying-off of bleeding blood vessels.
• laparotomy – surgery to open the abdomen to find the cause of the bleeding.
• hysterectomy – surgical removal of the uterus; in most cases, this is a last resort.
Replacing lost blood and fluids is important in treating postpartum hemorrhage. Intravenous (IV) fluids, blood, and blood products may be given rapidly to prevent shock. The mother may also receive oxygen by mask.
• Predisposing conditions (eg, uterine fibroids, polyhydramnios, multifetal pregnancy, a maternal bleeding disorder, history of puerperal hemorrhage or postpartum hemorrhage) are identified antepartum and, when possible, corrected.
• If women have an unusual blood type, that blood type is made available ahead of time. Careful, unhurried delivery with a minimum of intervention is always wise.
• After placental separation, oxytocin 10 units IM or dilute oxytocin infusion (10 or 20 units in 1000 mL of an IV solution at 125 to 200 mL/hour for 1 to 2 hours) usually ensures uterine contraction and reduces blood loss.
• After the placenta is delivered, it is thoroughly examined for completeness; if it is incomplete, the uterus is manually explored and retained fragments are removed. Rarely, curettage is required.
• Uterine contraction and amount of vaginal bleeding must be observed for 1 hour after completion of the 3rd stage of labor.
Postpartum hemorrhage can be quite serious. However, quickly detecting and treating the cause of bleeding can often lead to a full recovery.
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