An obstetric hemorrhage is an obstetrical emergency which refers to heavy bleeding during pregnancy, labor, or the puerperium. It may occur before or after Delivery, but more than 80% of cases occur postpartum. A postpartum hemorrhage (PPH) is a major cause of maternal morbidity, and one of the top three causes of maternal mortality in both high and low per capita income countries. It can be fast, furious and frightening. It is more likely with a Cesarean birth. It most often happens after the placenta is delivered, but it can also happen later.
Many deaths occur because of a poor clinical response to massive bleeding and while in many countries this reflects a scarcity of resources, trained personnel and access to basic health care. A concerted effort is required in every country and community to optimize care with available resources and identify where improvements can be made.
Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate. As more blood is lost the women may feel cold, their blood pressure may drop, and they may become unconscious.
The most common cause of obstetric hemorrhage is the inability of uterus to contract and retract after delivery. Birthweight, labor induction and augmentation, chorioamnionitis, magnesium sulfate use, and previous PPH are all positively associated with increased risk of obstetric hemorrhage
Other risk factors are as follows:
- Retained placenta
- Failure to progress during the second stage of labor
- Placenta accreta
- Instrumental delivery
- Large-for-gestational-age (LGA) newborn
- Hypertensive disorders Induction of labor
- Augmentation of labor with oxytocin
By using the “4 T’ s” as a mnemonic (tone, tissue, trauma, and thrombosis), causes of obstetric hemorrhage can be remembered
- Tone: Uterine atony and failure of contraction and retraction of myometrial muscle fibers may result in severe hemorrhage.
- Trauma: If an injury happens to birth canal , uterus, cervix, perineum and vagina due to improper monitoring at the time of delivery, it creats substantial bleeding.
- Tissue: Placenta will be detached due to uterine contraction and retraction. Optimal blockage of blood vessels occur due to detachment and expulsion of the placenta.
- Thrombin: a bleeding disorder which occurs when there is a failure of clotting.
The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as soon as possible. Treatment includes:
- Stimulating uterine contractions using medicines and uterine massage.
- Removing pieces of the placenta that remain in the uterus
- To set pressure on bleeding inside the uterus, Bakri balloon or a Foley catheter can be used.
- Laparotomy: This is a surgical procedure in which abdomen is opened to find the cause of bleeding.
- Tying off or sealing bleeding blood vessels. The surgery is done during a laparotomy.
- Hysterectomy: This is surgery to remove the uterus. In most cases, this is a last resort.
Postpartum hemorrhage can be quite serious. Obstetric hemorrhage may be the most preventable cause of maternal mortality, if proper diagnosis and management is done.