Postpartum Hemorrhage (PPH) is a serious condition where a mother loses a lot of blood quickly during or right after giving birth. This can cause a big drop in her blood pressure, leading to shock and even life-threatening situations if not treated promptly. It’s important for people to know about PPH, understand the risks it poses to women, how it is identified, and the steps being taken to prevent and treat it today.
What is Postpartum Hemorrhage?
Bleeding during labor or after childbirth is a serious and common emergency in pregnancy. It is the leading cause of pregnant and postpartum women being admitted to intensive care units.
Maternal mortality due to hemorrhage ranges from 30% to 50%, affecting millions of women each year, and is commonly defined as a blood loss of 500 ml after vaginal delivery or 1,000 ml after cesarean section.
There are two types of postpartum hemorrhage:
Primary Postpartum Hemorrhage: This occurs within the first 24 hours after delivery.
Secondary Postpartum Hemorrhage: This happens between 24 hours and 12 weeks after delivery.
The most frequent signs of postpartum hemorrhage include:
- Heavy and uncontrolled bleeding.
- Reduction in blood pressure.
- Elevated heart rate.
- Decrease in red blood cell count.
- Swelling and discomfort in the vaginal area or nearby regions, especially if caused by hematoma.
Why Does Postpartum Hemorrhage Occur?
There are several reasons why postpartum hemorrhage may occur.
During pregnancy, the placenta attaches to the wall of the uterus and supplies nutrients and oxygen to the baby. After birth, the uterus continues to contract to expel the placenta, in what is known as the third stage of labor. These contractions also help compress the blood vessels where the placenta was attached. Sometimes, however, these contractions are not strong enough to stop the bleeding, which is called uterine atony, and is responsible for up to 80% of postpartum hemorrhages.
Postpartum hemorrhage can also occur if parts of the placenta remain attached to the wall of the uterus or if damage to the reproductive organs occurs during delivery. The risk of postpartum hemorrhage increases if you have a blood clotting disorder or certain health conditions.
Anyone can experience postpartum hemorrhage after childbirth. Although there are many risk factors, approximately 40% of hemorrhages occur in women without any risk factors. Most postpartum hemorrhage occurs immediately after delivery of the placenta and is more likely after a cesarean section.
Who is at Risk for Postpartum Hemorrhage?
Some women are more susceptible to suffering from postpartum hemorrhage. Here are some factors that can increase this risk:
- Placental abruption: When the placenta detaches from the uterus too early.
- Placenta Previa: When the placenta is located above or near the cervix.
- Overstretched uterus: Often due to excessive amniotic fluid or a large baby.
- Multiple babies: Having twins, triplets or more.
- Pregnancy-related hypertension: Conditions such as pre-eclampsia.
- Multiple births: Having given birth many times before.
- Prolonged labor: When labor lasts a long time.
- Infections: During pregnancy or childbirth.
- Obesity: A higher body mass index can increase the risk.
- Assisted childbirth: Use of forceps or vacuum extraction during delivery.
- Ethnicity: Being of Asian or Hispanic descent.
How is Postpartum Hemorrhage Diagnosed?
In addition to a complete medical history and thorough physical examination, the diagnosis of postpartum hemorrhage is mainly based on observed symptoms. Laboratory tests are crucial for confirming the diagnosis and include:
- Estimating blood loss by counting the number of saturated compresses or weighing the dressings and sponges used to absorb blood (approximately 1 gram equals 1 milliliter of blood).
- Measuring heart rate and blood pressure.
- Evaluating hematocrit levels to determine the number of red blood cells.
- Analyzing blood coagulation factors.
While postpartum hemorrhage is a serious complication that requires immediate attention, it is important to understand that some bleeding is to be expected during and after childbirth and can even be considered “normal”. The key is to know the difference between the two.
Bleeding After Birth (Lochia)
Lochia is the vaginal discharge that women experience after childbirth. This bleeding is a mixture of blood, mucus and placental tissue that the body expels as the uterus recovers and returns to its normal size.
Phases of Lochia:
Lochia goes through several stages:
- Lochia rubra: During the first 3 to 5 days, the bleeding is heavier and bright red. This discharge is similar to heavy menstruation and may contain small clots.
- Serous lochia: As the days pass, the discharge becomes pinker or browner and less intense. This phase usually lasts up to 10 days after delivery.
- Lochia alba: Eventually, the discharge becomes lighter or yellow-white. This stage may last from 2 to 6 weeks after delivery, with a gradual decrease in the amount of discharge.
Care During Postpartum Bleeding
- Use of sanitary pads: During this period, it is recommended to use superabsorbent sanitary pads instead of tampons, as tampons may increase the risk of infection. It is important to change them regularly to maintain good hygiene.
- Personal hygiene: Washing hands before and after changing sanitary napkins is essential to prevent infection. In addition, keeping the perineal area clean and dry aids in recovery.
- Monitoring bleeding: If bleeding suddenly becomes heavier, or if large clots are present, it is important to inform the midwife or physician. These may be signs of complications that require medical attention.
Changes During Lactation
- It is common for bleeding to increase during breastfeeding, which stimulates the release of oxytocin, a hormone that causes uterine contractions, helping the uterus return to its normal size more quickly. These contractions can cause cramping similar to menstrual cramps and a temporary increase in bleeding.
WHO Roadmap to Combat Postpartum Hemorrhage Between 2023 and 2030.
The World Health Organization (WHO), in collaboration with the International Federation of Gynecology and Obstetrics (FIGO), has developed a roadmap aimed at combating postpartum hemorrhage (PPH) between 2023 and 2030. This initiative responds to the urgent need to reduce maternal-fetal morbidity and mortality associated with complications from postpartum hemorrhage, which continues to be a significant cause of maternal mortality worldwide.
The roadmap is grounded in evidence-based practices and expert opinion, establishing clear objectives, strategic activities and specific milestones to advance global research, regulation, implementation and promotion of effective PPH measures. Its innovative approach is tailored to the unique needs of each country, especially those with a high burden of PPH and limited resources, seeking to mobilize investments in critical areas of health systems.
The main objectives of the roadmap include aligning international efforts, strengthening cooperation among diverse actors such as the international community, funders, researchers, innovators, professional associations and guideline development agencies. It also seeks to involve implementers, including civil society organizations and NGOs, as well as ministries of health and the general public, especially women, who are directly affected by PPH.
This initiative aims to meet the core priorities of the Sustainable Development Goals (SDGs), particularly target 3.1 to reduce maternal mortality globally. By promoting a comprehensive and collaborative approach, the roadmap aims to transform maternal and newborn health care, driving technical advances, strategic investments, and effective policies that are critical to improving health outcomes worldwide.
Postpartum hemorrhage is a serious public health problem that affects millions of women worldwide. It is important for society to be informed about this complication of pregnancy, its causes, symptoms and how to prevent it. In this way, pregnant women and their families can be better prepared. In addition, talking about postpartum hemorrhage helps to break the silence and taboo surrounding the difficulties of childbirth, making it easier for more women to ask for and receive the support they deserve.
