Postpartum haemorrhage

Some bleeding just after birth is normal with an acceptable amount of blood loss being up to 500 to 600 ml. More bleeding than this is not uncommon and requires additional management. The amount of blood loss after delivery is not predictable.

This is why haemoglobin and iron levels are checked during pregnancy and iron supplements recommended if levels are low. If haemoglobin is low (most commonly due to iron deficiency) during pregnancy and there is excess bleeding postpartum, then there is more chance of needing a blood transfusion for symptoms of anaemia (low haemoglobin).

After the baby is delivered, removal of the placenta uncovers a large area of blood vessels in the uterine wall. These vessels will only stop bleeding when the uterine muscle contracts around them and cuts off the blood supply.

Excess bleeding can occur if the placenta is retained, is slow to separate, partially separates, or if fragments of placenta or blood clot are left behind. Sometimes the uterine muscle is fatigued after labour and will not contract down without being encouraged by squeezing the uterus through the abdominal wall or giving medication to make the uterus contract. Bleeding can also occur from vaginal and cervical tears.

Routine measures

An injection of Syntocinon (synthetic oxytocin at a higher amount than natural levels) is given just after baby is born to make the uterus contract and help with separation of the placenta from the uterine wall. The placenta is removed as soon as there are signs of placental separation. After the placenta is removed the uterus is squeezed through the abdominal wall to make sure that it is firm and contracting down.

If the placenta does not separate it may be necessary to perform a manual removal of placenta. An anaesthetic (either regional or general) is required so that a gloved hand can be inserted inside the uterus and the placenta is separated from the uterine wall and removed. Usually this is done in Theatre and means that mother and baby are apart temporarily.

It is not possible to predict who will have heavy bleeding so every woman is given Syntocinon immediately after delivery to make the uterus contract. This reduces the number of women who have excess bleeding and retained placentas. It also minimizes complications of blood loss and requirement for additional management. Some women will still have excess bleeding even after receiving Syntocinon.

 

Other measures

Syntocinon can be mixed with Ergometrine (Syntometrine) and this combination can have a stronger effect on making the uterus contract down after delivery. Ergometrine may cause nausea, headache and transient increase in blood pressure so it is avoided if there is hypertension. It can be given in addition to Syntocinon or given as the routine injection especially if there is a past history of heavy bleeding at delivery.

Misoprostol is a prostaglandin in tablet form that can be given rectally to improve contraction of the uterus and reduce bleeding. Another prostaglandin can be injected into the uterine muscle. Tranexamic acid can be given intravenously to slow the breakdown of clots and reduce bleeding.

Emptying the bladder with an indwelling catheter may help as a full bladder can prevent the uterus from contracting down and stopping bleeding. Women who have an epidural will already have an bladder catheter in place but those without a catheter may require one sited after postpartum haemorrhage.

If there is heavy bleeding, blood will be collected to check the blood count and have blood in the laboratory that can be used to cross-match blood if a blood transfusion is required.

Bakri Catheter

It is possible to insert a catheter inside the uterus and fill this with water to put pressure on blood vessels inside the uterus to prevent ongoing bleeding. If there is not an epidural block, an anaesthetic may be required for insertion of a Bakri catheter.

The Bakri catheter is left inside the uterus for 24 hours. After this time, the fluid is sucked out of the balloon and the tubing is removed through the vagina. By this time the bleeding will have resolved.

Examination under Anaesthesia and further surgery

If heavy bleeding persists after these measures, then examination under anaesthesia in Theatre may be required. Any retained placental tissue or blood clots can be removed from the uterus and any lacerations to the birth canal repaired. Mother and baby will be temporarily apart during the procedure in theatre.

If life-threatening bleeding persists, other operative procedures may be necessary. Laparotomy (opening the abdomen surgically in a similar way to a Caesarean procedure) allows access to uterine arteries leading to the uterus. It is possible to tie off uterine arteries to reduce blood supply to the uterus. A large suture can be placed and tied around the uterus lengthways to increase muscular pressure on the bleeding vessels inside the uterus. As a last resort, a hysterectomy (surgical removal of the uterus) may be necessary to save the life of the mother.

 

After a Postpartum Haemorrhage

Excessive bleeding may result in requirement for a blood transfusion and admission to the adult Intensive Care Unit for close observation. This means that mother and baby will be apart while the mother is in ICU.

In the ward after a postpartum haemorrhage, a close watch is kept on blood loss, heart rate, blood pressure and the firmness of the uterus through the abdominal wall to ensure that further management is not required.

The following day the blood count and iron levels can be checked by blood test. If the haemoglobin is very low or borderline with symptoms of anaemia, a blood transfusion may be needed. If the haemoglobin and iron levels are low, an intravenous infusion of iron may aid in recovery of the blood count without a blood transfusion.