What is postpartum haemorrhage?
A postpartum haemorrhage (PPH) is heavy bleeding after the birth of your baby. There are two types, primary and secondary.
Primary PPH is defined as the loss of more than 500ml of blood in the first 24 hours after the birth, and occurs in about five per cent of all deliveries.
Secondary PPH occurs in about one per cent of births, and is any abnormally heavy bleeding that happens 24 hours to six weeks after the birth (most happen 5-10 days after delivery).
What causes postpartum haemorrhage?
In the vast majority of cases primary PPH is simply down to the uterus not contracting down properly after the birth, which is known in medical terms as uterine atony. It may also be caused by bleeding from tears to the vagina, perineum or cervix, a blood clotting disorder or a retained placenta.
In secondary PPH bleeding may be due to small pieces of the placenta or membrane being retained in the uterus or to an infection.
How will I know if it’s happening?
You may feel the blood trickling out, but if it builds up inside your uterus, you may not realise until signs of shock appear, eg a drop in blood pressure and a rise in your pulse rate, or you feel faint and dizzy.
Your midwife will regularly check your fundus, the top of your uterus, after delivery by feeling it to make sure it stays firm and contracted, and your blood pressure will be monitored regularly immediately after the birth.
What treatment will I receive?
If your uterus is not firm and contracted, your midwife may ‘rub up’ a contraction and may give you another oxytocin injection to help things along.
If the bleeding is very severe, a blood transfusion may be needed. It is rarely life-threatening given the right care and facilities (there are about 8.5 deaths per million births from PPH, just to show how minimal that risk is).
For secondary PPH, antibiotics and sometimes dilatation and curettage (D&C), an operation to empty the uterus, may be necessary.
Tell me more about uterine atony
Once the placenta is delivered, the uterus should contract strongly to shut off all the blood vessels where the placenta was attached. This happens naturally but can be speeded up with an injection of oxytocin. If the uterus is relaxed instead of contracted, the vessels will bleed. The following are all risk factors – the more that are present, the higher the risk of haemorrhage.
- Very short or very long labour
- After a Caesarean, whether emergency or elective (the risk increases the more C-sections you have)
- Following an assisted delivery (ventouse or forceps) and where an episiotomy has been performed
- Multiple pregnancy
- Having had four or more babies previously
- Multiple pregnancy
- Bleeding during pregnancy (antepartum haemorrhage or APH)
- Placenta praevia
- Presence of fibroids
What are the chances of it happening in subsequent pregnancies?
The recurrence rate is 20-25 per cent, so you are at greater risk, but your caregivers will be aware of your history and ready to step in. You may be advised to have your next baby in hospital, just in case.
Can I prevent it, now or for future pregnancies?
The most obvious way to prevent PPH is to opt for a managed third stage, where you are given an oxytocin injection to speed up the delivery of the placenta – this reduces the risk by 60%. It’s also worth making sure you’re not anaemic going into the birth, so keep eating healthily and take iron supplements if necessary.