Postpartum Haemorrhage (PPH): Causes, Symptoms, Treatment & Prevention

What Is Postpartum Haemorrhage (PPH)?

PPH happens when a mother loses too much blood after giving birth. Doctors categorise it as primary PPH (first 24 hours) or secondary PPH (24 hours to 12 weeks after birth). Blood loss becomes PPH when it surpasses 500ml after vaginal delivery or 1000ml after a caesarean section. The condition ranges from minor (500-1000ml of blood loss) to major (more than 1000ml).

Why Postpartum Haemorrhage Happens

Doctors use the "four Ts" to explain PPH's main causes:

• Tone: Uterine atony (when the uterus doesn't contract properly) - this accounts for 70-80% of cases

• Trauma: Tears in the cervix, vagina or uterus

• Tissue: Pieces of placenta left behind

• Thrombin: Problems with blood clotting.

Risk Factors for PPH

Certain conditions increases your chances of developing PPH. These include:

• Placental complications (previa, abruption)

• Carrying twins or a large baby

• A previous PPH experience

• Labour that lasts too long

• Obesity

• Age above 35 years.

Symptoms and Warning Signs of PPH

These signs need immediate medical attention:

• Blood soaks through a sanitary pad within an hour

• Blood clots bigger than a golf ball pass

• Dizziness, confusion, or fainting spells

• Skin feels cold and clammy

• The heart beats unusually fast

• Sharp pain in the abdomen.

Diagnosis

Doctors diagnose PPH by carefully observing blood loss and performing physical examinations. Visual estimation is common but it often underestimates volume by 33-50%. Quantitative measurements are more accurate. Weighing blood-soaked items (1g equals 1ml of blood) gives a better picture. The shock index (heart rate divided by systolic blood pressure) helps determine severity and values ≥0.9 show significant blood loss.

Treatment Options for Postpartum Haemorrhage

The first step aims to stop bleeding while maintaining circulation. This includes:

• First-line treatments: Uterine massage, bimanual compression, and oxytocin (10-40 IU) administration

• Second-line medications: Methylergometrine, carboprost, or misoprostol if bleeding continues

• Non-surgical interventions: Balloon tamponade, where a balloon inserted through the vagina applies direct pressure to bleeding sites

• Surgical options: Uterine artery embolisation (success rate >90%), compression sutures, or hysterectomy as a last resort

Prevention of Postpartum Haemorrhage

• Active management of the third stage of labour reduces PPH occurrence by a lot. This includes giving oxytocin (10 IU) right after delivery.

• High-risk patients need to be identified before childbirth so necessary resources can be prepared.

• If a pregnant woman has anaemia treating it before delivery reduces the chances of PPH.

• Quick handling of a stuck placenta or birth damage reduces PPH risk.

• Controlled cord traction and uterine massage encourage the uterus to contract after the placenta comes out.

You Should Get Emergency Medical Care

Get emergency help if you have:

• Heavy bleeding that soaks through one pad hourly

• Blood clots larger than an egg

• Dizziness, weakness or fainting

• Rapid heartbeat or trouble breathing

• Severe abdominal pain.

FAQs

1. What is postpartum haemorrhage (PPH)?

   PPH happens when a mother experiences excessive bleeding after giving birth. Doctors call it PPH when blood loss reaches 1,000 millilitres or more, whatever the delivery type. Mothers might experience PPH right after birth (primary) or within 12 weeks (secondary).

2. What are the common causes of postpartum haemorrhage?

   Doctors identify four main causes of PPH (known as the "four Ts"):

   • Tone: Uterine atony occurs when your womb doesn't contract properly and causes 80% of cases

   • Trauma: Birth canal or uterus tears

   • Tissue: Pieces of placenta that stay behind

   • Thrombin: Problems with blood clotting.

3. How much bleeding is considered normal after childbirth?

   Normal bleeding (lochia) can last up to six weeks. Dark red bleeding appears during the first two weeks. Blood loss typically reaches half a quart after vaginal delivery or a quart after caesarean section. The colour changes from brown to yellowish-white as time passes.

4. What are the symptoms of postpartum haemorrhage?

   Symptoms of postpartum haemorrhage include sudden or excessive vaginal bleeding after delivery, passage of large clots, severe weakness, or dizziness. Women might also have rapid pulse, low blood pressure, pale clammy skin, reduced urine output, and a feeling of breathlessness. It's crucial to get medical help right away.

5. How is postpartum haemorrhage treated?

   Doctors work quickly to stop bleeding. They use:

   • Medications help stimulate uterine contractions

   • Uterine massage helps control bleeding.

   • Uterine massage helps control bleeding

   • Removal of any remaining tissue helps recovery

   • Special balloon devices compress the area to reduce bleeding.

   • Severe cases might need surgery.

6. Can postpartum haemorrhage be prevented?

   PPH cannot always be prevented, but several strategies reduce the risk. These are:

   • Active management of the third stage of labour decreases PPH by a lot

   • Treating anaemia before delivery

   • Receiving 10 units of oxytocin immediately after birth

   • Clear communication about previous bleeding issues with your healthcare team

7. Are certain women at higher risk for PPH?

   The risk increases with:

   • Placental problems (previa, abruption)

   • Multiple pregnancies or large babies

   • Previous PPH history (3-fold increased risk)

   • Pre-eclampsia

   • Obesity

   • Blood clotting disorders.

8. When should I seek immediate medical help for PPH?

   Emergency services should be called if you:

   • Soak through one pad within an hour

   • Pass blood clots larger than an egg

   • Experience dizziness, weakness or fainting

   • Notice a rapid heartbeat or breathing

   • Develop severe abdominal pain.

9. Can postpartum haemorrhage affect future pregnancies?

   PPH history usually doesn't affect fertility. But women who experienced PPH have:

   • 3-6 times higher risk of recurrence

   • Slightly lower likelihood of subsequent pregnancy after caesarean with PPH

10. What are the long-term complications of severe PPH?

    Severe PPH can lead to:

    • Persistent psychological problems including PTSD symptoms

    • Increased cardiovascular disease risk years after delivery

    • Physical complications from treatments

    • Anaemia and related fatigue.