Loss of blood greater than 500ml after delivery of the baby is called postpartum haemorrhage. Most PPH will occur at third and fourth stages of labour. On the previous labour and delivery module of session five, you have learned the six steps to be followed in ATSML (Active third stage management of labour). If you remember Session 1 of this module about the critical time in which maternal and neonatal death will occur; almost 90% of all postpartum haemorrhage will take place within the first four hours after delivery.
Even though 90% of all postpartum haemorrhage occurs during the first four hours after delivery; it can also occur at later times during the first one week eventually and up to six weeks of the puerperal period. Based on the time of its occurrence, postpartum haemorrhage is classified into two major groups.
i. Early (acute) postpartum haemorrhage: This is the one which will occur from the time of placental delivery (due to mismanagement of active third stage of labour) up to the first four hours.
ii. Secondary (late) postpartum haemorrhage: This type of postpartum haemorrhage can occur from the first week after delivery and up to the whole (six weeks) puerperal period.
Stop for a while and think of the next question
What do you think will cause both types of postpartum haemorrhage? Do you think that the causes of both early and late PPH are the same?
You are allowed one minute to discuss it with your friend beside you. What do you think then? Have you got the right answer? Ok, don‘t worry you will get the answer from the next section
If you have said that the causes of postpartum haemorrhage will differ with its classifications, you are correct.The causes of postpartum haemorrhage are different for each type of postpartum haemorrhage.
Early or acute postpartum haemorrhage is mainly caused by the conditions those will occur at the time of delivery of the baby and the placenta.
a. When the whole or part of the placenta retained undetached on the endometrial wall this could be due to the mismanagement of the third stage most commonly or problem of the placenta and poor uterine contraction to fully expel the placenta which contributes to the retention of part of the placenta (placental nodes) or part of the amniotic membrane (fetal membrane) remains undetached from the placental wall and cause bleeding from the wall. This type of postpartum haemorrhage is called retention PPH. Retained fetal membranes can cause both early PPH and late PPH.
b. When there is a tear of different degree in the case of powerful contraction causing a forceful expulsion of the fetus (cervical tear or tear of the vaginal wall), and with medium contraction and expulsion force if the perineal area is left unsupported during extension of the fetal head which can cause a perineal tear. If postpartum haemorrhage occurs due to tear somewhere in the birth canal, it is called traumatic PPH.
c. Another cause of early PPH is called atonic PPH. It will occur when the uterine muscle loses its normal tone (do you know the muscular part of the uterus? Ok, if you say myometrium, you are correct). This means that the myometrium will lose its natural strength to contract and relax). The myometrium can lose its normal or natural strength due to different causes, but the main cause is repeated pregnancy (that means many pregnancies many times without interruption from year to year). In which case, atonic PPH is very common in mothers who gave birth for many children year to year without getting rest.Mainly your responsibility here is to give a pre-referral management for the mother. Can you tell some of the pre-referral management options? Ok, you will learn it in this section.
As the name implies, late postpartum haemorrhage starts lately after one week of delivery. And the causes of it will slightly differ from that of the early one. Can you tell the causes of early PPH? Late PPH mainly depends on the presence of long-standing problems those can complicate and cause PPH. Some of the causes of late PPH are: -
a. Infection of the reproductive organs during the antenatal or natal period like PROM (premature rupture of membrane), Infections of the pelvic areas like PID (pelvic inflammatory disease), and any infection of the endometrial wall. The main point you have to know here is that how infection can cause bleeding. When there is an infection, there is wounding of that infection area and in some causes, this area may bleed and cause PPH and cause the uterus to contract poorly.
b. Poorly contracted uterus: This means that due to infection of the endometrial wall, the uterus fails to contract well. And this will cause PPH at later times.
c. Sloughing of the endometrial wall on the placental bed: This means that, the wall of endometrium on which the placenta was situated, will heal after the placenta was separated and expelled. But some times what happens is, the already healed part of the placental bed will slough again and leave the blood vessels to be open again, and this will cause bleeding of the blood vessels leading to late PPH.
d. Molar pregnancy: If you remember from your ANC module, molar pregnancy is a non-fetal, grape-like abnormal cellular growth in the uterus, and due to which the uterus looks like in a pregnant state. But it is not a true pregnancy. This molar pregnancy if it occurs it can cause severe bleeding from the uterine wall. Even though it is unlikely for a molar pregnancy to occur immediately after pregnancy; but occasionally if it occurs it can cause severe bleeding.
Postpartum haemorrhage (PPH) is a major cause of mortality, morbidity and long-term disability related to pregnancy and childbirth. Effective interventions to prevent and treat PPH exist and can largely reduce the burden of this life-threatening condition.
As a health extension worker, you are the first to come across with such life-threatening conditions. In which case, you are expected to have the necessary knowledge when to refer the mother.