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Postpartum haemorrhage

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

Postpartum haemorrhage (PPH) is defined as excessive bleeding from the genital tract at any time following the baby's birth up to 12 weeks after birth;

  • If it occurs during the third stage of labour or within 24 hours of delivery, it is termed primary postpartum haemorrhage.
  • If it occurs subsequent to the first 24 hours following birth up until the 12th week postpartum, it is termed secondary postpartum haemorrhage.

Primary postpartum haemorrhage

A measured loss that reaches 500 ml or any loss that adversely affects the mother's condition constitutes a PPH. There are several reasons why a PPH may occur, including:

  • Atonic uterus
  • Retained placenta
  • Trauma
  • Blood coagulation disorder.

Atonic uterus

This is a failure of the myometrium at the placental site to contract and retract, and to compress torn blood vessels and control blood loss by a living ligature action. Causes of atonic uterine action resulting in PPH are:

  • Incomplete separation of the placenta
  • Retained cotyledon, placental fragment or membranes
  • Precipitate labour
  • Prolonged labour resulting in uterine inertia
  • Polyhydramnios or multiple pregnancy causing overdistension of uterine muscle
  • Placenta praevia
  • Placental abruption
  • General anaesthesia, especially halothane or cyclopropane
  • Mismanagement of the third stage of labour
  • A full bladder
  • Aetiology unknown


There are, in addition, a number of factors that do not directly cause a PPH, but do increase the likelihood of excessive bleeding:

  • Previous history of postpartum haemorrhage or retained placenta
  • High parity, resulting in uterine scar tissue
  • Presence of fibroids
  • Maternal anaemia
  • Ketoacidosls
  • Multiple pregnancy

Signs of PPH

These may be obvious, such as visible bleeding or maternal collapse, or more subtle, such as pallor, rising pulse rate, falling blood pressure, altered level of consciousness. The mother may become restless or drowsy, and have an enlarged uterus that feels 'boggy' on palpation (i.e. soft, distended and lacking tone), even if little blood loss is visible.


  • During the antenatal period, identify risk factors, e.g. previous obstetric history, anaemia.
  • During labour, prevent prolonged labour and ketoacidosis.
  • Ensure the mother does not have a full bladder at any stage.
  • Give prophylactic administration of an uterotonic agent.
  • If a woman is known to have a placenta praevia, keep 2 units of cross-matched blood available.

Management of PPH

Three basic principles of care:

  • Call for medical aid
  • Stop the bleeding:
  • Rub up a contraction
  • Give an uterotonic
  • Empty the bladder
  • Empty the uterus
  • Apply pressure if there is trauma.
  • Resuscitate the mother

Secondary or delayed PPH

This is where there is excessive or prolonged vaginal loss from 24 hours after delivery of the placenta and for up to 12 weeks postpartum. Unlike primary PPH, which includes a specified volume of blood loss as part of its definition, there is no such volume defined for secondary PPH. Regardless of the timing of any haemorrhage, it is most frequently the placental site that is the source. Alternatively, a cervical or deep vaginal wall tear or trauma to the perineum might be the cause in women who have recently given birth. Retained placental fragments or other products of conception are likely to inhibit the process of involution, or reopen the placental wound. The diagnosis is likely to be determined by the woman's condition and pattern of events and is also often complicated by the presence of infection.

Signs of secondary PPH


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