A gynaecologist, Dr. Nurudeen Bello, talks about postpartum haemorrhage with TOPE OMOGBOLAGUN
What is postpartum haemorrhage?
Post-partum haemorrhage is one of the leading causes of maternal mortality, especially in this part of the world. It is often defined as the loss of more than 500ml or 1,000 millilitres of blood after delivery. Any form of bleeding that occurs in the uterus of a woman after the birth of a child is called postpartum haemorrhage.
What are the types of postpartum haemorrhage?
There are two types of postpartum haemorrhage– primary and secondary. The bleeding that occurs 24 hours after delivery is called the primary postpartum haemorrhage while the secondary PPH is excessive bleeding that occurs sometime after delivery. The most common one that we have is the primary postpartum haemorrhage.
What are the causes of PPH?
Basically, the causes are classified into four. The first has to do with uterine atony which is the most common cause of haemorrhage. There are certain things that can bring about uterine atony after delivery. It is usually as a result of pre-existing conditions in the mother before she gave birth.
Another thing that can lead to such condition is multiple pregnancies; that is if a woman is carrying more than one foetus. Polyhydramnios, that is excessive amiotic fluid in the foetus, can also lead to it. Also, uterine fibroid can cause postpartum haemorrhage. A patient with anemia, especially chronic one, that is low level of blood, is also at risk of postpartum haemorrhage. A woman, who has been delivered of babies more than five times, can easily have post-birth bleeding. A patient, who has anti-partum haemorrhage, that is bleeding of the vagina before delivery, can also experience PPH. The condition that led to the woman bleeding before delivery can continue even after the delivery of the child. Those are the factors responsible for uterine atony.
We have other cause such as trauma, not necessarily physical trauma, but it includes things like vagina lacerations, cervical laceration or uterine rapture. Vagina laceration, commonly referred to as tear, is what occurs after childbirth and if it is not managed, can lead to postpartum haemorrhage.
Some may have tear in the vagina wall as a result of poor condition of the delivery or a woman can have cervical laceration, which could be as a result of tearing down the wall of the cervix. The cervix is the mouth of the womb that dilates to allow the baby to be delivered. If the woman pushes against the cervix before it is fully dilated to unnecessarily hasten the delivery of the baby, it can cause a tear of the cervix and a complication of that can lead to postpartum haemorrhage.
A woman can have PPH as a result of uterine rapture caused by prolonged obstructed labour or a person who had a caesarean section in the past or a form of uterine surgery in the past without proper monitoring before going into labour. It could also happen as a result of injudicious use of medications to give strength for uterine contraction. If they are not well used, it would lead to uterine rupture and then postpartum haemorrhage.
It can also be caused by post-birth factors, routine process of conception, that is, issue left behind after the birth of a child. Usually, when a woman is delivered of a baby, the placenta and the membrane should be completely delivered. But there are instances where the placenta is left inside as a whole or sometimes some parts of it are left inside and as a result, the woman continues to bleed because the uterus is not allowed to contrast. The placenta may be delivered while the membrane that covers the water sac is still left inside. All these can lead to postpartum haemorrhage.
Postpartum haemorrhage is also caused by throndin, a methodological condition, that is, shortage of certain things in the blood. You could have a pre-existing condition like haemophilia A, B and the rest or a complication during pregnancy like disseminated intravascular coagulation. What that means is that the things responsible for clotting of blood in that woman are not working and instead of the blood to clot for the bleeding to stop, the woman will continue to bleed. Other rare causes of post-partum haemorrhage are amiotic fluid embolism and the rest.
Are there factors that can indicate if a new mother may experience PPH?
In most cases, a doctor can pre-empt that a patient can have postpartum haemorrhage and the thing to look out for are those factors that have been mentioned earlier. The factors include multiple pregnancy, co-existing uterine fibroid, a patient who had been delivered of babies more than five times or a patient who had gone through uterine surgery, including caesarean section or in the past such a patient had placenta accrete. If a patient has prolonged or obstructed labour, then, we should know that the patient will have postpartum haemorrhage.
How can PPH be prevented?
Postpartum haemorrhage is usually prevented by the uterus contracting by itself. So, it is usually prevented by the uterus naturally contracting by itself or the use of some drugs to aid the contraction of the uterus. But if the uterus cannot contract, then the possibility that the woman will continue to bleed is high.
PPH is a condition that is difficult to predict. What I will advise is that every delivery, especially high rate delivery, should be handled in a facility where there are enough manpower and blood transfusion 24hours in a day.
The leading way of managing postpartum haemorrhage is active management of labour to stop the bleeding. The first stage is to find a way between the delivery of the child and that of the placenta. That time interval is critical to postpartum haemorrhage especially primary postpartum haemorrhage. What is done is the administration of oxytocin within one minute of the delivery of the baby and running a form of contraction for the uterus. This has been known to reduce primary postpartum haemorrhage. But some, no matter what you do, will still have primary postpartum haemorrhage. This is when you need to manage postpartum haemorrhage.
If by measuring, you discover that the person has postpartum haemorrhage, to manage it, make sure that the patient is on intravenous line and do oxytocin if it has not been done. Then, you take a blood investigation and test-match blood for possible transfusion. The initial time is very critical in the management of PPH.
If the patient is in a facility where there is enough manpower, they can quickly make the diagnosis and help the patient.
What are some of ways to manage someone experiencing PPH?
Like I said, the first stage is the active management to prevent the bleeding. Like I said, the major cause of it in our environment is uterine atony and this can be managed, medically, mechanically or surgically.
The medical management involves the use of drugs called oxytocin. We also use mechanical method like uterine vacuum like balloon and all that is used to compress the uterus. We can also use what is called bi-manual compression of the uterus. Where facility is available, we can also do what we call interventional radiology. Prompt repair of the tear will help save the woman from bleeding to death.
If things get really complicated, we might also do a surgery where we remove the uterus but that is usually the last option. If the bleeding is as a result of anomaly in the blood vessels, there will be a need for blood transfusion.
Secondary haemorrhage is usually as a result of either a chain product of conception or endometritis – infection of the lining of the womb. The treatment will either be to remove the uterus of the chain products or the use of antibiotics and some other medical report.
Does postpartum haemorrhage affect fertility?
Yes, it can in several ways. One of the ways in which PPH can affect the womb is if a patient has bled so much, especially in the case of PPPH. The patient can have a condition we call Sheehan’s syndrome caused by damage to the pituitary, thereby causing a decrease in one or more hormones it normally secretes. Since the pituitary controls many glands in the endocrine system, partial or complete loss of a variety of functions may result.
They may not be able to produce the hormones responsible for egg production for the ovaries, and such, patient may have problems with ovulation and that will lead to infertility.
Another way that PPH can affect fertility is if a patient is predisposed to infection of the genital tract in the puparium. If a patient has endometritis, infection of the lining of the womb, it can lead to a condition called uterine addiction such a person will have issues with conception.
The third way PPH can affect the fertility of a woman is if a patient’s womb gets removed as a result of complications. The person cannot carry a baby in her womb again. Those are the links between PPH and infertility.
What is your advice to pregnant women?
My first advice is that procreation is a necessity but we should keep it as simple as possible. We should keep our family size within what we can take care of. By so doing, a woman will be saved from PPH if she doesn’t have to go through labour five times. We should seek advice from health practitioners and a good health care facility with enough manpower.
Any patient that is at risk of postpartum haemorrhage should be duly registered. The patient should attend antenatal classes promptly and ensure that she is properly monitored.