Postpartum haemorrhage

This is bleeding from the genital tract after the delivery of a baby.

It can be broadly divided into primary and secondary types, the distinction being the timing of the onset of the bleed relative to the delivery (1,2).

A primary postpartum haemorrhage is a loss (usually defined as more than 500ml) in the first 24 hours after delivery.

It is important to note that in pregnancy the clinical parameters may be unreliable; for example, apparent normotension can be due to pre-eclampsia combined with blood loss.

Postpartum bleeding - Postnatal Care (3)

Discuss with women what vaginal bleeding to expect after the birth (lochia), and advise women to seek medical advice if:

• the vaginal bleeding is sudden or very heavy
• the bleeding increases
• they pass clots, placental tissue or membranes
• they have symptoms of possible infection, such as abdominal, pelvic or perineal pain, fever, shivering, or vaginal bleeding or discharge has an unpleasant smell
• they have concerns about vaginal bleeding after the birth

If a women seeks medical advice about vaginal bleeding after the birth, assess the severity, and be aware of the risk factors for postpartum haemorrhage

• Antenatal risk factors:
• previous retained placenta or postpartum haemorrhage
• maternal haemoglobin level below 85 g/litre at onset of labour
• BMI greater than 35 kg/m2
• grand multiparity (parity4 or more)
• antepartum haemorrhage
• overdistention of the uterus (for example, multiple pregnancy, polyhydramnios or macrosomia)
• existing uterine abnormalities
• low-lying placenta
• maternal age of 35 years or older.
• Risk factors in labour:
• induction
• prolonged first, second or third stage of labour
• oxytocin use
• precipitate labour
• operative birth or caesarean section

Also be aware of the following factors, which may worsen the consequences of secondary postpartum haemorrhage:

• anaemia
• weight of less than 50 kg at the first appointment with the midwife during pregnancy (booking appointment).

Prevention of postpartum haemorrhage (2):

• traditionally, oxytocin and ergot preparations have been used as uterotonic agents for postpartum haemorrhage prophylaxis mostly as part of active management of the third stage of labour
  • a major disadvantage, mainly related to ergot preparations, is the relatively high incidence of side-effects such as nausea, vomiting and increase in blood pressure
• misoprostol may prevent severe postpartum haemorrhage but the evidence is inconsistent
  • misoprostol or intramuscular postaglandins are not more effective than conventional injectable uterotonics - both lead to more adverse effects
  • the review concludes that neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.

Reference:

1. NICE (September 2007). Intrapartum care.
2. Gulmezoglu AM et al. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD00049
3. NICE (April 2021). Postnatal care