Postpartum bleeding or postpartum hemorrhage (PPH) is significant blood loss following childbirth. It is the most common cause of maternal death worldwide, disproportionately affecting developing countries. Definitions and criteria for diagnosis are highly variable. PPH is defined by the World Health Organization as "blood loss of 500 ml or more within 24 hours after birth", though signs of shock (insufficient blood flow) have also been used as a definition. Some bleeding after childbirth is normal and is called lochia. It is difficult to distinguish lochia from delayed PPH. Signs and symptoms of PPH may initially include: an increased heart rate, feeling faint upon standing, and an increased breathing rate. As more blood is lost, the patient may feel cold, blood pressure may drop, and they may become restless or unconscious. In severe cases circulatory collapse, disseminated intravascular coagulation and death can occur. The condition can occur up to twelve weeks following delivery. The most common cause of PPH is insufficient contraction of the uterus following childbirth; this contraction normally stops the blood flow that supplies the fetus during pregnancy. Other causes are retained placenta, where the placenta is not expelled after childbirth; a tear of the uterus, cervix, or vagina; or poor blood clotting. PPH is more likely to occur in people who are Asian, are obese, previously had PPH or have an anemia, give birth to a large baby or more than one fetus, or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, those requiring the use of a vacuum or forceps, and those who have an episiotomy. Prevention involves decreasing known risk factors including procedures associated with the condition, if possible, and giving the medication oxytocin to stimulate the uterus to contract shortly after the baby is born. Misoprostol may be used instead of oxytocin in resource-poor settings. Treatments may include: intravenous fluids, blood transfusions, and the medication ergotamine to cause further uterine contraction. Efforts to compress the uterus using the hands may be effective if other treatments do not work. The aorta may also be compressed by pressing on the abdomen. The World Health Organization has recommended the non-pneumatic anti-shock garment to help until other measures such as surgery can be carried out. Tranexamic acid has also been shown to reduce the risk of death, and has been recommended within three hours of delivery. In the developing world about 1.2% of deliveries are associated with PPH and when PPH occurred about 3% of women died. It is responsible for 8% of maternal deaths during childbirth in developed regions and 20% of maternal deaths during childbirth in developing regions. Globally it occurs about 8.7 million times and results in 44,000 to 86,000 deaths per year making it the leading cause of death during pregnancy. About 0.4 women per 100,000 deliveries die from PPH in the United Kingdom while about 150 women per 100,000 deliveries die in sub-Saharan Africa. Rates of death have decreased substantially since at least the late 1800s in the United Kingdom.
Definition Depending on the source, primary postpartum bleeding is defined as blood loss in excess of 500 ml following vaginal delivery or 1000 mL following caesarean section in the first 24 hours following birth. Others have defined the condition as blood loss of greater than 1000 mL after either delivery method, or any amount of blood loss with signs and symptoms of hypovolemia. Secondary postpartum bleeding is that which occurs after the 24 hours up to 12 weeks after childbirth.
Signs and symptoms Symptoms generally include heavy bleeding from the vagina that doesn't slow or stop over time. Initially there may be an increased heart rate, feeling faint upon standing, and an increased respiratory rate. As more blood is lost, the patient may feel cold, blood pressure may drop, and they may become unconscious. Signs and symptoms of circulatory shock may also include blurry vision, cold and clammy skin, confusion, and feeling sleepy or weak.
Causes
Causes of postpartum hemorrhage are uterine atony, trauma, retained placenta or placental abnormalities, and coagulopathy, commonly referred to as the "four Ts":
Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony. Uterine atony is the most common cause of postpartum hemorrhage. Trauma: Injury to the birth canal which includes the uterus, cervix, vagina and the perineum which can happen even if the delivery is monitored properly. The bleeding is substantial as all these organs become more vascular during pregnancy. Tissue: retention of tissue from the placenta or fetus as well as placental abnormalities such as placenta accreta and percreta may lead to bleeding. Thrombin: a bleeding disorder occurs when there is a failure of clotting, such as with diseases known as coagulopathies. Risk factors with a strong association with postpartum hemorrhage included anemia, previous postpartum hemorrhage, caesarean birth, female genital mutilation, sepsis, no antenatal care, multiple pregnancy, placenta praevia, assisted reproductive technology use, macrosomia with a birthweight of more than 4500 g, and shoulder dystocia. Risk factors with moderate association with postpartum hemorrhage included obesity defined as BMI ≥30 kg/m2, COVID-19 infection, gestational diabetes, polyhydramnios, pre-eclampsia, and antepartum hemorrhage. Other risk factors include endometriosis, fever during pregnancy, bleeding before delivery, and heart disease.
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