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bleeding (postpartum haemorrhage)

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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.

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.

Risk factors for postpartum haemorrhage

  • women with risk factors for postpartum haemorrhage should be advised to give birth in an obstetric unit where more emergency treatment options are available.
    • antenatal risk factors:
      • previous retained placenta or postpartum haemorrhage
      • maternal haemoglobin level below 8.5 g/dl at onset of labour
      • body mass index greater than 35 kg/m2
      • grand multiparity (parity 4 or more)
      • antepartum haemorrhage
      • overdistention of the uterus (for example, multiple pregnancy, polyhydramnios or macrosomia)
      • existing uterine abnormalities e.g fibroids
      • low-lying placenta
      • maternal age (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.

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.

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