Post-partum hemorrhage (PPH) literally means excessive bleeding post delivery. This is an obstetric emergency (if nothing is done it can be life-threatening), and accounts for about 25 – 40% of deaths in women following delivery (maternal mortality) worldwide. This figure is higher in Africa due to lack of adequate health coverage for all women especially for women who live in the rural areas and hinterlands.
This bleeding is defined as loss of more than 500mls of blood post vaginal delivery or more than a liter following cesarean section. It is also defined as any blood loss severe enough to lead to hemodynamic instability(instability in the blood circulatory system, with resultant clinical sequelae, such as drastic fall in blood pressure, dizziness, collapse, or even shock)in a woman who just had a delivery.
There are 2 types of PPH: primary and secondary.
Primary-PPH occurs within the first 24 hours following delivery. This is usually life threatening because it is caused by factors associated with delivery.
- Uterine atony is the commonest cause of PPHwhich occurs when the uterus does not contract sufficiently.
- Perineal laceration is another important cause which can be in the form of cervical laceration, vaginal, vulva tear or bruises sustained during delivery, poorly repaired episiotomy site, vulva hematoma etc. These areas are likely to bleed profusely if not well sutured.Also, placenta and other tissue can be retained following delivery and this can be prevented by inspecting the main placenta before discarding.
Other causes include disseminated intravascular coagulopathy, uterine rupture and uterine inversion.
Secondary PPH usually occurs after the first 24 hours and up to 6 weeks post-delivery. This is usually due to infection, commonly caused by retained products of conception.
- MANAGEMENT OF PPH
Management of PPH depends on the cause, some of which have been discussed in this article. Excessive blood loss can either be managed in the labour room, if mild, or in the theatre, if severe.If there is uterine atony, administration of oxytocic medication, rubbing off contractions, emptying the urinary bladder will help stop bleeding. Patient may need blood transfusion depending on severity of bleeding. If these measures fail more drastic measures can be undertaken by the Obstetrician.
In the event that the placenta or membrane is retained, the doctor will attempt to remove it under anesthesia in the theatre.
If perineal laceration is the cause of the bleed, your Obstetrician will look for where this is and repair it to stop the bleeding.
The important thing to note is to attend antenatal care in a hospital where you can easily access your Obstetrician with good blood banking or laboratory services like Kelina Hospital in the advent of an emergency like post partum hemorrhage.
That apparently innocuous bleed could spell a disaster when not properly attended to and could lead to death.
Dr. Olufolake A. Oni