Postpartum Hemorrhage
Postpartum Hemorrhage
What is postpartum
hemorrhage?
Postpartum hemorrhage is excessive bleeding following the birth of a baby.
About 4 percent of women have postpartum hemorrhage and it is more likely with a cesarean
birth. Hemorrhage may occur before or after the placenta is delivered.
The average amount of blood loss after the birth of a single baby in vaginal
delivery is about 500 ml
(or about a half of a quart). The average amount of blood loss for a cesarean
birth is approximately 1,000 ml (or one quart). Most postpartum hemorrhage
occurs right after delivery, but it can occur later as well.
What causes postpartum
hemorrhage?
Once a baby is delivered, the uterus normally continues to
contract (tightening of uterine muscles) and expels the placenta. After the
placenta is delivered, these contractions help compress the bleeding vessels in
the area where the placenta was attached. If the uterus does not contract
strongly enough, called uterine
atony, these blood vessels bleed freely and hemorrhage occurs. This is
the most common cause of postpartum hemorrhage. If small pieces of the placenta remain attached,
bleeding is also likely. It is estimated that as much as 600 ml (more than a
quart) of blood flows through the placenta each minute in a full-term pregnancy.
Some women are at greater risk for postpartum hemorrhage than
others. Conditions that may
increase the risk for postpartum hemorrhage include the following:
- placental abruption - the early
detachment of the placenta from the uterus.
- placenta previa - the placenta
covers or is near the cervical opening.
- overdistended uterus - excessive
enlargement of the uterus due to too much amniotic fluid or a large baby,
especially with birthweight over 4,000 grams (8.8 pounds).
- multiple pregnancy - more than one
placenta and overdistention of the uterus.
- pregnancy-induced hypertension
(PIH) - high blood pressure of pregnancy.
- having many previous births
- prolonged labor
- infection
- obesity
- medications to induce labor
- medications to stop contractions
(for preterm labor)
- use of forceps or vacuum-assisted delivery
- general anesthesia
Postpartum hemorrhage may also be due to other factors including
the following:
- tear in the cervix or vaginal tissues
- tear in a uterine blood vessel
- bleeding into a concealed tissue area or space in
the pelvis which develops into a hematoma, usually in the vulva or vaginal
area
- blood clotting disorders such as disseminated
intravascular coagulation
- placenta accreta - the placenta
is abnormally attached to the inside of the uterus (a condition that
occurs in one in 2,500 births and is more common if the placenta is
attached over a prior cesarean scar).
- placenta increta - the
placental tissues invade the muscle of the uterus.
- placenta percreta - the
placental tissues go all the way into the uterine muscle and may break
through (rupture).
Although an uncommon event (one in 2,000 deliveries), uterine
rupture can be life threatening for the mother. Conditions that may increase
the risk of uterine rupture include surgery to remove fibroid (benign) tumors
and a prior cesarean scar in the upper part (fundus) of the uterus. It can also
occur before delivery and place the fetus at risk as well.
Why is postpartum
hemorrhage a concern?
Excessive and rapid blood loss can cause a severe drop in the
mother's blood pressure and may lead to shock and death if not treated.
What are the symptoms of
postpartum hemorrhage?
The following are the most common symptoms of postpartum
hemorrhage. However, each woman may experience symptoms differently. Symptoms
may include:
- uncontrolled
bleeding
- decreased
blood pressure
- increased
heart rate
- decrease
in the red blood cell count (hematocrit)
- swelling
and pain in tissues in the vaginal and perineal area
The symptoms of postpartum hemorrhage may resemble other
conditions or medical problems. Always consult your physician for a diagnosis.
How is postpartum
hemorrhage diagnosed?
In addition to a complete medical history and physical examination, diagnosis is usually based
on symptoms, with
laboratory tests often helping with the diagnosis. Tests used to diagnose
postpartum hemorrhage may include:
- estimation of
blood loss (this may be done by counting the number of saturated pads, or
by weighing of packs and sponges used to absorb blood; 1 milliliter of
blood weighs approximately one gram)
- pulse rate and
blood pressure measurement
- hematocrit (red
blood cell count)
- clotting
factors in the blood
Treatment for postpartum
hemorrhage:
Specific treatment for postpartum hemorrhage will be determined by
your physician based on:
- your pregnancy, overall health, and
medical history
- extent of the condition
- your tolerance for specific
medications, procedures, or therapies
- expectations for the course of the
condition
- your opinion or preference
The aim of
treatment of postpartum hemorrhage is to find and stop the cause of the
bleeding as quickly as possible. Treatment for postpartum hemorrhage may
include:
- medication (to
stimulate uterine contractions)
- manual massage
of the uterus (to stimulate contractions)
- removal of
placental pieces that remain in the uterus
- examination of
the uterus and other pelvic tissues
- packing the
uterus with sponges and sterile materials (to compress the bleeding area
in the uterus)
- tying-off of
bleeding blood vessels
- laparotomy -
surgery to open the abdomen to find the cause of the bleeding.
- hysterectomy -
surgical removal of the uterus; in most cases, this is a last resort.
Replacing lost blood and fluids is important in treating
postpartum hemorrhage. Intravenous (IV) fluids, blood, and blood products may
be given rapidly to prevent shock. The mother may also receive oxygen by mask.
Postpartum hemorrhage can be quite serious. However, quickly
detecting and treating the cause of bleeding can often lead to a full recovery.
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