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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;
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:
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:
There are, in addition, a number of factors that do not directly cause a PPH, but do increase the likelihood of excessive bleeding:
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.
Management of PPH
Three basic principles of care:
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