Postpartum hemorrhage: Leading Cause Of Death After Childbirth

Postpartum hemorrhage (PPH) refers to heavy bleeding that occurs after childbirth, and it is one of the leading causes of maternal mortality. PPH is defined as blood loss of more than 500 milliliters following a vaginal delivery or more than 1000 milliliters following a cesarean section, though the severity can vary.

There are two types of postpartum hemorrhage:

1. Primary (Early) Postpartum Hemorrhage – occurs within the first 24 hours after delivery.
2. Secondary (Late) Postpartum Hemorrhage – occurs after the first 24 hours but within 6 weeks after childbirth.

Causes of Postpartum Hemorrhage:

1. Uterine Atony (Failure of Uterus to Contract)
   • The most common cause of PPH is uterine atony, which occurs when the uterus fails to contract effectively after delivery. This reduces the ability of blood vessels to constrict, leading to excessive bleeding. It can result from:
     • Over-distended uterus (e.g., from multiple pregnancies, large baby, or excess amniotic fluid)
     • Prolonged labor or rapid delivery
     • Use of certain medications (e.g., oxytocin or magnesium sulfate)
     • Retained placenta
2. Trauma to the Birth Canal
   • Tears in the cervix, vagina, or perineum can lead to significant bleeding. This might happen during a difficult or assisted delivery, such as with the use of forceps or a vacuum extractor.
3. Retained Placenta
   • When parts of the placenta remain in the uterus after childbirth, it can cause continued bleeding. The placenta may not detach properly or may remain adhered to the uterine wall (placenta accreta).
4. Coagulation Disorders
   • Women with underlying bleeding disorders, such as hemophilia or von Willebrand disease, or those who develop clotting issues during pregnancy (like disseminated intravascular coagulation, DIC), are at higher risk for severe bleeding.
5. Uterine Rupture
   • A rare but life-threatening complication where the uterus tears, leading to massive bleeding.

Risk Factors for Postpartum Hemorrhage:

• Previous PPH or history of uterine atony
• Multiple pregnancies or multiple births
• Large baby (macrosomia)
• Prolonged labor or rapid delivery
• Infection (especially during labor or delivery)
• Obesity
• High blood pressure or preeclampsia
• Use of blood-thinning medications (e.g., aspirin, warfarin)
• Placental problems, such as placenta previa (placenta covering the cervix) or placenta accreta

Symptoms of Postpartum Hemorrhage:

• Excessive vaginal bleeding (more than expected)
• Large blood clots
• Rapid heart rate or low blood pressure
• Pale, clammy skin
• Lightheadedness, dizziness, or fainting
• Decreased urine output

Treatment of Postpartum Hemorrhage:

• Uterotonic Medications: Drugs like oxytocin, misoprostol, or ergometrine are given to stimulate uterine contractions, helping to stop bleeding.
• Manual Removal of Placenta: If the placenta is retained, it may need to be manually removed by a doctor.
• Surgical Intervention: In severe cases, surgical procedures such as a D&C (dilation and curettage), or even a hysterectomy (removal of the uterus) might be necessary to control the bleeding.
• Blood Transfusion: If blood loss is substantial, a transfusion may be required to stabilize the woman.
• Balloon Tamponade or Compression Sutures: In some cases, a balloon may be inserted into the uterus to apply pressure and stop bleeding, or sutures can be used to tighten the uterus.

Prevention:

• Active management of the third stage of labor: This involves administering uterotonic drugs immediately after birth, controlled cord traction to help deliver the placenta, and massaging the uterus to encourage contraction.
• Monitoring for Risk Factors: Identifying and managing high-risk pregnancies, such as those with multiple births or large babies, can help prevent PPH.
• Timely Response: Recognizing early signs of PPH and initiating treatment quickly can help prevent it.