Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is excessive bleeding after childbirth, generally defined as blood loss of 500 mL or more after vaginal delivery. It is a leading cause of maternal death and requires immediate emergency management.

• Heavy vaginal bleeding after delivery of the baby (and placenta)
• Signs of shock: rapid heart rate, low blood pressure, pallor, dizziness, or loss of consciousness
• A soft, poorly contracted uterus on examination in the most common cause (uterine atony)

• Uterine atony (failure of the uterus to contract firmly after delivery) is the most common cause.
• Retained placenta or placental fragments.
• Trauma to the birth canal, such as tears of the cervix or vagina.
• Underlying bleeding or clotting disorders, though these are less common causes.

• Diagnosed clinically by estimating blood loss and assessing for signs of shock.
• Examination is used to identify the likely cause — checking uterine tone, looking for retained placental tissue, and inspecting for genital tract trauma.

This is an emergency requiring immediate action. Initial steps include uterine massage and giving a uterotonic medicine — oxytocin is the first-line agent, given immediately after delivery to prevent PPH and also used to treat it.

Misoprostol is used as an alternative uterotonic where oxytocin is unavailable or as an additional measure.

Tranexamic acid is given early to reduce bleeding due to trauma.

Intravenous fluids and, where needed, blood transfusion are given to treat or prevent shock.

Any retained placental tissue or genital tract trauma is identified and managed promptly, with rapid referral to a facility capable of emergency obstetric care, including surgery, if bleeding is not controlled.

• Give a uterotonic medicine (oxytocin) routinely immediately after every delivery as part of active management of the third stage of labour.
• Ensure skilled attendance at every birth so bleeding can be identified and managed quickly.
• Treat anaemia during pregnancy, as it increases the risk of complications from blood loss.
• Plan for referral and transport in advance for women giving birth far from a facility with emergency obstetric care.