Heavy bleeding after birth/ postpartum haemorrhage (PPH)

What is postpartum haemorrhage (PPH)?

It is normal to have significant bleeding during and after childbirth, which should reduce over time and stop in about 4-6 weeks. Postpartum haemorrhage is when you have heavy bleeding of 500ml or more after birth. If this happens in the first 24 hours after childbirth, it is considered primary PPH. If this occurs between 24 hours and 12 weeks after childbirth, it is considered secondary PPH.

Why does heavy bleeding after birth happen?

Many women who experience heavy bleeding after birth do not have risk factors, and vice versa. Some of the risk factors include:

• Low-lying placenta/placenta previa: placenta is near to (<2cm away), or covers part of/all of the cervix (neck of womb).
• Placenta accreta: the placenta grows into, and is very stuck to, the muscle of the uterus.
• Placental abruption: premature separation of placenta from uterus 
• Having twins or more 
• Pregnancy induced hypertension/ pre-eclampsia
• History of heavy bleeding after previous birth
• Obesity
• Anaemia (low blood count) or blood clotting problems
• Having uterine fibroids
• Induction of labour
• Caesarean section (higher risk if under general anaesthesia)
• Episiotomy
• Assisted vaginal delivery (vacuum or forceps)
• Long labour 
• Large baby 
• Having fever during labour 
• Retained placenta

How will I know if I have primary PPH?

You may feel faint or giddy. Heavy bleeding after birth can happen quickly and is considered an emergency as it may turn potentially life-threatening, so you may have people rushing into your room.

What tests will I need for primary PPH?

You will need intravenous plugs to draw bloods for tests and to run fluids through a drip. Your temperature, blood pressure, pulse rate and oxygen levels will be monitored closely. Your gynaecologist will check the size and tone of your uterus through your abdomen and vagina, your episiotomy/ vaginal tears, and your placenta to ensure that you do not have any retained placenta bits. 

How is primary PPH treated?

Depending on your condition, you may require:

• Uterine massage: through your abdomen and vagina to encourage your uterus to contract and stop bleeding
• Urinary catheter: to drain your urine and encourage your uterus to contract 
• Intravenous plugs: to run fluids, give medications and blood transfusions (if necessary)
• Medications: This can be given intravenously, intramuscularly, or rectally. It can also be injected directly into your uterus (if you are having a C-section)
• Manual removal of placenta: if your placenta is retained, your gynaecologist will need to remove it either in the labour room (if you have an epidural) or in the operating theatre 
• Insertion of uterine balloon: this is a balloon device that is inserted into your uterus to apply pressure and stop bleeding
• Uterine artery embolization or Hysterectomy: this is usually the last resort when life-saving measures are needed. Small particles are injected to block off the blood vessels supplying your uterus or the uterus is surgically removed through a laparotomy (open) incision. 

You may need monitoring in a high-dependency or intensive care unit until you stabilise, after which you will be allowed to eat, drink, move about and breastfeed.

After your bleeding and blood counts stabilise, you will be given either intravenous or oral iron supplements as you will still be anaemic and may feel tired. Your blood count may take 6 weeks or longer to go back to normal levels. 

How will I know if I have secondary PPH?

You may experience:

• Bleeding that is getting heavier after you have left the hospital 
• Your lochia is foul-smelling 
• Fever 

What tests will I need for secondary PPH?

Your gynaecologist will need to take a detailed history and do a pelvic examination. As secondary PPH is usually related to infection or retained placenta bits in your uterus, vaginal swabs will be sent to check for infection, and an ultrasound scan performed to check the thickness of your uterine lining. You may need blood tests. 

How is secondary PPH treated?

You will require intravenous antibiotics (this will be changed to oral once you improve). If there is suspicion of retained placenta bits, you will need to undergo a surgical evacuation to wash out the contents inside your uterus. 

I’ve had heavy bleeding after birth during my last delivery. Will it happen again in my next one?

You do have an increased risk of having PPH in your subsequent deliveries. You should speak to your gynaecologist about it and take oral iron supplements during your pregnancy to ensure your blood count is good and you are not anaemic.