Postpartum Hemorrhage

All pregnant women experience postpartum bleeding in the days and weeks following birth. This is normal and is a sign that your uterus is healing. However, some women may experience postpartum hemorrhage (PPH) following labor and delivery. This abnormal postpartum bleeding can be life threatening and requires immediate medical attention.

PPH: The Facts
Postpartum hemorrhage is most commonly defined as losing 500ml of blood or more after a vaginal birth or 1000ml of blood or more after a cesarean. If this significant loss of blood occurs within 24 hours of childbirth, it is considered to be early or primary postpartum hemorrhage. After 24 hours, if postpartum hemorrhaging occurs, it is referred to as late or secondary postpartum hemorrhaging. The majority of PPH occur within 24 hours after labor.

Postpartum hemorrhaging is the leading cause of maternal mortality. Although the rates of maternal mortality are quite low in the developed world, in countries where there is a lack of skilled health care providers along with poor transportation and emergency services, the numbers are much higher. Without the proper medical attention, a woman can die within two hours of hemorrhaging. The World Health Organization suggests that as many as 25% of maternal deaths worldwide are caused by postpartum hemorrhage.

Causes of Postpartum Hemorrhage
In the majority of cases, PPH is the result of the failure of the uterus to properly contract and retract after birth. This is known as uterine atony. Other causes of PPH include:

Failure to deliver the placenta
Forced removal of the placenta
Trauma to the genital tract (i.e. use of forceps, uterine rupture, lacerations)
Clotting disorders
Sometimes, inducing labor

Who Is at Risk?
Effectively, pretty much any woman who carries her pregnancy past 20 weeks gestation is at risk of experiencing postpartum hemorrhaging. Because as many as two thirds of women who hemorrhage have no identifiable risk factors, it is strongly encouraged that health care providers monitor every pregnant woman for PPH. Some factors that have been suggested as possibly increasing a woman’s chances of hemorrhaging include:

Experiencing postpartum hemorrhage in a previous pregnancy
Having a multiple birth
Carrying more than five pregnancies to term
Inducing labor, particularly with pitocin
Delivering a large baby
Placenta previa

Treating PPH
There are a number of ways that postpartum hemorrhaging can be treated, depending on the severity of the hemorrhaging. Some PPH can be stopped through massaging the uterus, administering oxygen or by raising your feet above your heart, known as the trendelenberg position.

Often, an attempt to stop the bleeding is made by administering drugs, including pitocin, methergine and hemabate. In some cases, surgery may be necessary to stop the bleeding. Typical surgeries include a ligation of the uterus and the hypogastric artery, whereby these two organs are joined together, and/or a hysterectomy, which involves removing your uterus. However, both of these surgeries can have repercussions on your fertility.

Thanks to the advancement of microsurgeries, a more common technique that is being used these days is balloon occlusion with embolization. With this procedure, a balloon is inflated in the uterus to immediately stop the bleeding. Next, a specialist will use a catheter to deposit tiny plastic particles into the uterine artery, thereby helping to temporarily block the bleeding. Because the excess blood flow is stopped quickly, these procedures can reduce the need for blood transfusions.

Preventing the Blood Loss
Active management of the third stage of labor has been shown to significantly help reduce the occurrence of postpartum hemorrhage. The main steps you and your health care provider can take to prevent PPH from occurring are:

Taking an uterotonic medication, usually oxytocin or misoprostol within a minute of delivery. This drug will cause the uterus to contract. However, some hospitals are choosing to hold off on the medication, allowing the body time to start contracting the uterus naturally.
Massaging the uterus. Some women may find this uncomfortable or even painful; relaxing your muscles, especially your abdominals, and using the breathing techniques you learned for labor can help make it more bearable.
Breastfeeding as soon as you can after birth. Your body will produce its own oxytocin when you start to breastfeed, which will aid in causing uterine contractions and the expulsion of the placenta naturally.

When You Leave the Hospital
Although the majority of incidents of PPH occur within 24 hours after birth, some women will experience postpartum hemorrhage in the initial weeks following labor. It is important to monitor your postpartum bleeding for any changes and to contact your health care provider immediately if you notice any of the following: