Postpartum hemorrhage (PPH) is heavy bleeding after giving birth. It’s a serious but rare condition. It usually happens on first day of giving birth, but it can happen anytime upto 12 weeks after having a baby. Research shows upto 5 in 100 women who have a baby can land up in PPH.

Losing some blood is normal after giving birth. Women usually lose about 500 ml during vaginal birth or about 1,000 ml after a cesarean birth (also called c-section).  In PPH, Blood loss is much more leading to a dangerous situation. PPH can cause a severe alteration in the vitals. If not treated immediately, this will cause to shock and death. 

WHAT CAUSES POSTPARTUM HEMORRHAGE?

After delivery of baby, the uterus contracts pushing out the placenta. After the placenta is delivered, these contractions puts pressure on the bleeding vessels at the placental attachment site. If the uterus doesn’t contract strongly enough, these blood vessels bleed freely. Small pieces of the placenta attached can also lead to bleeding. 

Conditions that affect the uterus

• Uterine atony. This is the foremost common cause of PPH. It is the condition when the muscles in your uterus remains relaxed after birth. It usually happens if uterus is stretched or enlarged from giving birth to twins or a large baby. It also can happen if you’ve already had several children, you’re in labor for a long time or you have too much amniotic fluid (fluid that surrounds your baby).
• Uterine inversion. This is a rare condition when the uterus turns inside out after delivery of the baby with or without placenta.
• Uterine rupture. This is when the uterus tears during the process of labor. It happens rarely. It may happen in cases of scared uterus from previous surgeries on the uterus. 

Conditions that affect the placenta

• Placental abruption. Placenta separates partially or completely before birth.
• Placenta accreta, placenta increta or placenta percreta- Placenta do not separate after delivery as it has grown deep into the uterine wall.
• Placenta previa– Placenta lie over cervix in the lower segment of the uterus which do not contract after delivery.
• Retained placenta- Placenta is not delivered within 30-60minutes of delivery. Sometimes even after placental delivery, a small part can be left in the uterus leading to PPH.

 Conditions during labor and birth

• Having a c-section 
• Getting general anesthesia. Usually needed only in cases of emergency c-section. It can cause uterine relaxation.
• Taking medicines to induce labor.   
• Taking medicines to stop or prevent preterm labor. If you have preterm labor, your doctor may give you medicines called tocolytics to slow or stop contractions.
• Tearing (also called lacerations). This may happen if a part of vagina or cervix are cut or torn during birth. This can happen following birth of a large baby, your baby is born through the birth canal too quickly or you have an episiotomy that tears. Tearing also can happen if your doctor have to use forceps or a vacuum, to help move your baby through the birth canal during birth. 
• A quick labor or prolong labor. Labor is different for every woman.  

Other conditions

• Clotting disorders, like von Willebrand disease or disseminated intravascular coagulation (also called DIC). -can increase your risk of forming a hematoma. 
• Infection, like chorioamnionitis.-infection of the placenta and amniotic fluid.
• Intrahepatic cholestasis of pregnancy (also called ICP). It can alter clotting mechanism.
• Obesity. 
• Preeclampsia or gestational hypertension. These are conditions with high blood pressure in pregnant women. 

WHAT ARE THE SYMPTOMS OF PPH?

Each woman may experience symptoms differently but most common are:

• uncontrolled bleeding
• decreased blood pressure
• increased heart rate
• decrease in the red blood cell count.
• swelling and pain in the vaginal and perineal area

DIAGNOSIS

Your doctor may use these tests to see if you have PPH or try to find the cause for PPH:

• Blood tests for clotting factors.
• Hematocrit – It checks the percent of your blood (called whole blood) that’s made up of red blood cells. Bleeding can cause a low hematocrit.
• Blood loss measurement – To evaluate the blood loss, your doctor may weigh or count the number of pads and sponges used to soak up the blood. 
• Pelvic exam – For tears and haematomas.
• Physical exam – For your vitals.
• Ultrasound– to check for problems with the placenta or uterus. TREATMENT

It depends on what’s causing your bleeding. The aim is to find and stop the cause of the bleeding as soon as possible. It may include:

• Getting fluids, medicine (like Pitocin) or having a blood transfusion – to maintain the blood volume lost in PPH.
• Examination of the uterus and other pelvic tissues, the vagina, and the vulva to look for areas that may need repair
• Bakri balloon or a Foley catheter to put pressure on the bleeding area inside the uterus. 
• Surgery, like a hysterectomy or a laparotomy. It is the last resort when other treatments are not working. Laprotomy is needed to find out the cause of bleeding and hysterectomy is done when uterus fails to contract inspite of all measures or is torn beyond repair.  
• Massaging the uterus by hand. Help to contract the uterus.
• Getting oxygen by mask
• Removing any remaining pieces of the placenta from the uterus.
• Embolization of the blood vessels of the uterus. It’s used in special cases and may prevent a hysterectomy. 
• Taking extra iron supplements along with a prenatal vitamin. 

COMPLICATIONS

Mild PPH can lead to anemia, but severe PPH can lead to serious consequences like shock or even Death.