Following the birth of a child, there is a risk of uterine haemorrhage. In an unsupervised birth there is a 20% chance of a large haemorrhage greater than 1000 ml (1 L), 20% of the total blood volume in a pregnant woman. In a well-supervised birth, that risk is significantly reduced to a 5% chance of a large haemorrhage.
Heavy bleeding after a baby is born (postpartum haemorrhage) is a complication of pregnancy that has the potential to be very serious, even resulting in death in rare cases. Some women will have risk factors for heavy bleeding, but most will not. This means that it is very difficult to predict when heavy bleeding might occur, and essentially all women giving birth are at risk of having a severe postpartum haemorrhage.
The use of some simple measures – receiving a small dose of medication to help the uterus contract after birth and assisting with delivering the placenta – all reduce the risk of heavy bleeding.
When heavy bleeding occurs, the birth attendants must act quickly and use proven techniques to stop the bleeding and help the woman recover.
Because postpartum haemorrhage occurs so unpredictably, all women giving birth should have timely access to skilled care and all the resources needed for managing heavy bleeding. This is one of many reasons why the college recommends that all women give birth in (or adjacent to) an appropriately equipped hospital.
Why does postpartum haemorrhage occur?
Women may occasionally request physiological (natural) management of the third stage without the use of an oxytocic (a medication that is often used by obstetricians to assist the uterus in contracting). It is important that these women are adequately informed of the increased risks of bleeding associated with this practice.
What are my risk factors, and what can I do to reduce the chances of this occurring?
A large number of risk factors for PPH have been identified, but most cases of PPH have no identifiable risk factor. For those women known to have risk factors for PPH, appropriate management should be instigated in both the antenatal and intrapartum periods to mitigate this risk.
All women should give birth in a unit with rapid access to blood and blood products and have antenatal correction of anaemia. Where a woman is likely to decline the administration of blood products, the risk of death from postpartum haemorrhage becomes considerably greater, and prophylaxis is even more important than otherwise.
What are important considerations in the event of abnormal placentation?
All women must have placental location determined by antenatal ultrasound. Appropriate recognition, preparation and management of women with placenta praevia or suspected morbidly adherent placentation is crucial, as these conditions are associated with increased risk of catastrophic haemorrhage.
Risk Factors
- Long labour or very fast labour
- Big babies
- Assisted birth
- Fibroids in the uterus
- Induced labours
- Twin births
How will my doctor manage this risk?
Active management of the third stage of labour (administration of prophylactic oxytocics and assisting delivery of the placenta) should be recommended to all pregnant women, as this reduces the risk of PPH and the need for blood transfusion.
Prophylactic oxytocics should be recommended for the management of the third stage of labour, whether following vaginal or caesarian birth, as they reduce the risk of PPH by more than 80%.
Management options include
- Multiple medications
- Placement of temporary uterine balloons
- Surgical exploration and placing surgical packs
- Surgical occlusion of the large uterine arteries
- Compression sutures around the uterus
- Hysterectomy
- Blood placement (transfusion)
Will postpartum haemorrhage impact my chances of having future children?
This will depend on the extent of treatment required.
If this has happened once, what is the likelihood it will occur in my next pregnancy?
- This will depend on the cause and if that cause has a possibility of occurring again.
- Avoidance of recurrent risk factors
- A proactive approach usually stems another future episode
Is this more common after a vaginal delivery?
- Large haemorrhage is more frequent after vaginal delivery.
