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Haemorrhage

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

Haemorrhage is literally the escape of blood from any blood vessel. In pregnancy, the two main types of haemorrhage of particular concern are antepartum haemorrhage (APH) and postpartum haemorrhage (PPH).

Antepartum haemorrhage

Bleeding from the genital tract after the 24th week of gestation and before the onset of labour. If the bleeding is severe it may be accompanied by shock and disseminated intravascular coagulation (DIC). It can be fatal or result in permanent ill health. Fetal mortality and morbidity are also increased as a result of severe vaginal bleeding in pregnancy. Stillbirth or neonatal death may occur. Premature placental separation and consequent hypoxia may result in severe neurological damage to the baby.

Causes and incidence of bleeding in late pregnancy

Cause Incidence (%)
Placenta praevia 31
Placental abruption 22
'Unclassified', e.g.
Marginal
Show
Cervicitis
Trauma
Vulvovaginal varicosities
Genital tumours
Genital infections
Haematuria
Vasa praevia
Other
47

APH is unpredictable and the woman's condition can deteriorate rapidly. A rapid decision about the urgency of need for a medical or paramedic presence or both must be made while observing the woman:

  • Take a history
  • Observe pulse rate, respiratory rate, blood pressure and temperature
  • Assess amount of blood lost
  • Perform a gentle abdominal examination, observing for signs that the woman is going into labour
  • On no account must any vaginal or rectal examination be done; nor may an enema or suppository be given to a woman suffering from APH

Fetal condition

  • Ask the mother if the baby has been moving as much as usual
  • Attempt to auscultate the fetal heart; ultrasound apparatus may be used

Diagnosis

Pain - did the pain precede bleeding and is it continuous or intermittent?

Onset of bleeding - was it associated with any event such as abdominal trauma or sexual intercourse?

Amount of visible blood loss - is there any reason to suspect some blood has been retained in utero?

Colour of the blood - bright red or dark?

Consistency of the abdomen - soft, or tense and board-like?

Tenderness of the abdomen - does the woman tense on examination palpation?

Lie, presentation and engagement - are any of these abnormal taking account of parity and gestation?

Audibility of fetal heart - is the fetal heart heard?

Ultrasound scan - does a scan suggest that the placenta is in the lower uterine segment?

See also, Placenta praevia

Further reading

National Institute for Health and Care Excellence (2014). Intrapartum care for healthy women and babies. Clinical guideline (CG190). Available at: https://www.nice.org.uk/guidance/cg190

Royal College of Obstetricians & Gynaecologists (2011). Antepartum haemorrhage (Green-top guideline No 63). Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf

Postpartum haemorrhage (PPH)

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 occurs during the third stage of labour or within 24 hours of delivery. A measured loss that reaches 500 ml or any loss that adversely affects the mother constitutes a PPH. There are several reasons why PPH may occur, including:

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

Signs may be obvious, such as visible bleeding or maternal collapse, but more subtle signs may present, including

  • Pallor
  • Rising pulse rate
  • Falling blood pressure
  • Altered level of consciousness
  • An enlarged uterus that feels 'boggy' on palpation, i.e. soft, distended and lacking tone, even if little visible blood loss

Prophylaxis

  • Identify risk factors (high parity, presence of fibroids, maternal anaemia, ketoacidosis, multiple pregnancy)
  • Prevent prolonged labour and ketoacidosis
  • Ensure the mother does not have a full bladder at any stage
  • Administer a uterotonic agent
  • If a woman is known to have a placenta praevia, keep 2 units of cross matched blood available

Management of PPH

The three principles of care:

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

Further reading

Royal College of Obstetricians & Gynaecologists (2009, revised April 2011) Postpartum haemorrhage, prevention and management (Green-top guideline No 52). Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/gt52postpartumhaemorrhage0411.pdf

Harding M. (2015). Postpartum haemorrhage (Professional reference). Available at: http://patient.info/doctor/postpartum-haemorrhage

Secondary postpartum haemorrhage

Secondary PPH is excessive or prolonged vaginal loss from 24 hours after delivery and for up to 12 weeks postpartum. 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. Diagnosis is likely to be determined by the woman's condition and the pattern of events, and is often complicated by the presence of infection.

Signs of secondary PPH

  • Lochial loss Is heavier than usual
  • Lochia returns to a bright red loss and may be offensive
  • Subinvolution of the uterus
  • Pyrexia and tachycardia
  • Haematoma formation

Treatment

  • Call a doctor
  • Rub up a contraction by massaging the uterus if it is still palpable
  • Express any clots
  • Encourage the woman to empty her bladder
  • Give an uterotonic drug intravenously or by intramuscular injection
  • Keep all pads and linen to assess volume of blood lost
  • Antibiotics may be prescribed
  • If retained products of conception are seen on an ultrasound scan, surgery may be required

Further reading

Royal College of Obstetricians & Gynaecologists (2009, revised April 2011) Postpartum haemorrhage, prevention and management (Green-top guideline No 52). Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/gt52postpartumhaemorrhage0411.pdf

Harding M. (2015). Postpartum haemorrhage (Professional reference). Available at: http://patient.info/doctor/postpartum-haemorrhage

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