Postpartum bleeding is currently posses the leading position in terms of maternal death.There are about 27 million women who acquire postpartum blood loss and it ultimately end up with 43,000 thousands maternal deaths The core reasons behind the occurrence of PPH are uterine atony,retained placenta along with coagulopathy.Moreover,caesarean section,anaemia and inappropriate antenatal care actually heighten the risk of occurring PPH in the pregnant mother.
In this article we try to share the concepts of prevention of postpartum hemorrhage which comprise reduction of number of caesarean sections together with the necessity of uterotonic prophylaxis.Fortunately standardised bundle and avoidance of delaying treatment protocol can certainly help save valuable lives.
What is primary postpartum bleeding or haemorrhage?
When excessive blood loss occurs from the gentinal tract of the mother within the 24 hours of the delivery, an estimated greater than 500 ml of fresh blood is called primary postpartum hemorrhage.It may have distinct classifications which comprise minor,major and secondary postpartum blood loss.While minor PPH means loss of blood less than 1000 mls,blood loss above 1000 mls actually suggest major PPH.
On the other hand,blood loss occurring between 24 hours post delivery period to six weeks of postpartum period indicates secondary postpartum blood loss or haemorrhage.
Common aetiologies of Primary postpartum blood loss
There are so many causes of post-partum hemorrhage that can trigger postpartum blood loss but we can broadly categorise these causes into “four Ts” namely;
Tonicity of uterus:It includes uterine atony along with distended bladder.
Trauma to the uterus:When there is any amount of lacerations of the uterus, cervix or vagina,it then triggers the occurrence of postpartum bleeding or haemorrhage.
Tissues within the uterine cavity:Retained placenta or presence of blood clots within the cavity after delivery of the fetus is among the vital causes of PPH. .
Pre-existent thrombin:Any amount of pre-existing coagulopathy which may be acquired also can have potential to cause serious postpartum hemorrhage in a mother during or after delivery.
However,uterine atony remains as the leading cause of PPH while the retained placenta leads the position as the second most common cause of postpartum blood loss.
Epidemiology of postpartum bleeding in global world
Obstetric haemorrhage continues to be the most frequent reason for obstetric morbidity and mortality in our entire globe.The percentage of occurrence of postpartum hemorrhage is about 1-3% of all deliveries and unfortunately it account for 8% of maternal deaths in the middle to high income country where low income countries consume 20% maternal deaths due to postpartum bleeding and its complication.
A report indicates that almost 70,000 maternal deaths occur due to postpartum blood loss together with its fatal complications in each year worldwide.As a more economically developed country the United States consumes about 11% of maternal deaths due to obstetric haemorrhages which usually occurs within the 24 hours of delivery or within the 6 weeks of postpartum period.
Usual risk or trigger factors of postpartum bleeding
There are some risk factors of post-partum hemorrhage which possess a close relation to the antenatal period and also some causes associate the delivery process of the baby.
Some common antenatal risk factors of PPH
- Antepartum haemorrhage in this pregnancy along with placenta praevia heightened the risk about 12 times than usual.
- Suspected or proven placental abruption together with multiple pregnancy increases the risk about 5 times.
- Another significant cause of PPH is uterine over-distention which include polyhydramnios or macrosomia.
- Pregnancy induces hypertension namely pre-eclampsia multiplies the risk of postpartum hemorrhage about 4 times than normal.
- Grand multiparas who have four or more pregnancies and also the nulliparas.
- Previous PPH or previously experienced retained placenta increases the risks about 3 times.
- Asian ethnicity also doubled the risks of postpartum bleeding or haemorrhage.
- Maternal obesity along with pre-existence uterine abnormality.
- Maternal age above 40 years along with maternal anaemia when Hb level is less than 9 g/dl.
The factors in relation to delivery of the baby
There are some factors which have a close relation to the delivery process of the baby and these factors usually increases the risk of PPH development.These comprise:
| Factors Increases the risk of PPH | |
| Emergency caesarean section(4x risk) | Weight of the baby >4 Kg |
| Over 3 elective caesarean sections | Maternal pyrexia or fever |
| Retained placenta also increases | Obstructions in the labour process |
| Mediolateral episiotomy(5 x risk) | Cephalopelvic disproportion |
| Iatrogenic Induction of labour | Incompetency of maternal cervix |
| Prolonged labour >12 hours from onset | Neuromuscular disorders |
Pre-existing maternal haemorrhagic conditions
There are some distinct maternal health conditions whose pre-existence in the maternal body heightened the risk of occurring postpartum hemorrhage.These comprise factor 8 deficiency which means mother is A haemophilia carrier and also factor 9 deficiency which indicates the mother is a hemophilia B carrier.
Therefore von Willebrand’s diseases also put the mother in great risk zones to experience the postpartum bleeding during delivery or within the 6 weeks of following delivery of the baby.
Core presentations of postpartum bleeding
These are some trademark features of postpartum hemorrhage which help the healthcare professionals to diagnose the postpartum bleeding early and appropriately.These comprise:
Symptoms of PPH: Continuous loss of fresh blood through the genital tract which healthcare professionals fail to stop after delivery of the placenta.
Signs of PPH:When the loss of blood exceeds 1000 ml after the delivery,it may produce shock and it might be clinically apparent through the notifiable tachycardia along with hypotension.
Correlation of other medical conditions
The sudden heavy loss may trigger the quick development of haemolysis, elevated liver enzymes and low platelets which is known as HELLP syndrome and the failure to manage them in a quick succession may worsen the patient’s condition.
Overall prompt diagnosis of postpartum bleeding or PPH
Healthcare providers usually diagnose post-partum hemorrhage through a combination of visual and physical examinations along with the assistance of some lab tests.Moreover, a thorough review of your health history may also be an important as well as crucial factor when it is about to assess the risk and health impacts of a PPH.
The diagnosis of postpartum hemorrhage is on the basis of the amount of blood you’ve lost during or after the delivery.One of the easiest ways to estimate blood loss after delivery is by carefully counting or weighing blood-soaked pads and sponges. If postpartum hemorrhage is suspected, your healthcare team may also use other tests or monitoring tools to assess your condition accurately.These include:
- Continuous monitoring of your vitals that include pulse rate and blood pressure to detect emergencies within the body.
- Several blood tests to measure red blood cells (hematocrit) and blood clotting or coagulation factors which may be the culprit of PPH.
- A thoroughly pelvic exam by the experts to check your vagina, cervix and uterus.
- Ultrasound and radiological imaging test to get a detailed image of your uterus and genital system.
Overall prompt treatment plan of PPH
Postpartum hemorrhage (PPH) is treated as a medical emergency because heavy bleeding can become dangerous quickly. The main priority is to find where the bleeding is coming from and stop it as soon as possible. Your healthcare provider will choose the most appropriate treatment based on the cause of the bleeding, how much blood you have lost, and whether it happens during or after childbirth.These comprise:
- Uterine massage to help the muscles of your uterus contract and ensure making it hard.
- Medications that stimulate uterine contractions and then remove retained placental tissue from your uterus which can happen manually or with instrumentally.
- Proper repair of vaginal, cervical, and uterine tears with appropriate stitches can help control bleeding. A catheter or balloon may also be used to apply gentle pressure inside the uterus that helps compress the uterine walls and reduce bleeding.
- Certain proven procedures with an expert’s hand can be beneficial to stop the blood supply to the uterus.
- There may be a need for blood transfusion if the bleeding is too much and your body demands along with fluids and supplemental oxygen.
When other methods fail,your healthcare team may perform surgery to stop the bleeding and this includes an abdominal incision (laparotomy) or the removal of the whole uterus via a hysterectomy as the situation demands.
How long does it take for you to recover from PPH?
Recovery is in fact different for everyone while the proper recovery from a postpartum hemorrhage depends solely on the severity of blood loss and how your healthcare provider tackled it.It is always advisable to you to make sure that you take care of yourself in the days following your delivery and ensure timely eating healthy foods and drinking lots of water as much as possible.
Your healthcare provider may recommend proper timely rest along with an iron supplement to you that can reduce your risk of anemia.
Complications of PPH in the mother
There are so many complications of post-partum hemorrhage which can bring about harmful and fatal health impacts to the delivering mother.These comprise:
- Hypovolaemic shock together with disseminated intravascular coagulation.
- Acute kidney injury along with concomitant liver failure.
- Acute (adult) respiratory distress syndrome and cardiac arrest which ultimately bring death to the patient with postpartum bleeding.
Prognosis of the patients or mothers with PPH
Severe bleeding during or after childbirth is actually the leading cause of maternal death in the entire globe that generally affects 14 million women each year and it is mostly prevalent in developing nations.However,the United States also struggles with uniquely high maternal mortality rates though this hemorrhage during or after childbirth is highly preventable.
Moreover it continues to claim general people’s lives and exposes the deep concern of racial inequities.Unfortunate,black women in the U.S possess the higher mortality rates due to postpartum hemorrhage over three times higher than White women and the excruciatingly demand urgent along with equitable care.
The main theme of prevention of the postpartum bleeding
The active management of the third stage of labour by the experts in this field can significantly reduce the risk of PPH and improve maternal well being as well.However prophylactic oxytocics should be routinely offered to the mothers in their third stage of labour and this is because they certainly decrease the risk of PPH by 60%.
Oxytocin 5 or 10 IU IM is preferably the prophylactic agent of choice in the management of postpartum hemorrhage for most women deliver vaginally.Experts recommend it to be used as an infusion for women who are undergoing caesarean sections and therefore Syntometrine (oxytocin along with ergometrine) may also be another potential option in the absence of hypertension during delivery.
Alternatives of the treatments for you facing PPH
Although oxytocin is the management or drug of choice in most of the cases of PPH, misoprostol can be an alternative in case of low resource delivery settings.The main advantages of it is that the availability of its oral form in the market which is comfortable to take.One study along with evidence indicate that it was more effective when given sublingually or directly under the tongue.
It is important for the healthcare authority to identify expectant mothers who may be at a higher risk for postpartum hemorrhage (PPH) so we can carefully plan the safest and standard location to conduct their delivery.
The Bottom line
While postpartum hemorrhage remains a menacing threat in global childbirth, it is irresistibly preventable for us.When we identify risk factors early and implement active labor management,it will then offer us safe maternal health and thereby reduce maternal deaths.Ultimately,the protection of mothers requires a steadfast commitment along with prompt clinical vigilance and timely intervention for every family.
