Talking about the post delivery bleeding which is an important clinical situation which can have some serious consequences on the health of woman if not managed properly at the same time, Dr Shivani Sachdev Gour, Gynaecologist and IVF Expert, SCI Healthcare shares her views on how one can manage the situation. She says that its management involves an aggressive approach which includes resuscitation of the compromised mother and also to find out the cause of bleeding. This involves oxygen administration, bimanual massage of uterus, immediate intravenous fluid administration and certain injections to contract the uterus which can stop the bleeding. If the blood loss is excessive, the woman might need blood transfusion. If the bleeding persists even after massage and injections then there may be some retained placental tissue or there might be a traumatic cause for which the patient needs to be shifted to the operating room and complete exploration of the genital tract is required by an expert and experienced assistants for evidence of any injury. She lists out absence of blood transfusion facilities and ignorance of illiterate women is the factors contributing to excessive bleeding after delivery. It can cause infection, blood transfusion reactions, thrombosis and failed lactation. In order to prevent post delivery bleeding one should pay proper attention to nutrition and a balanced diet should be taken daily.
After the delivery of baby, there is bleeding from the uterine bed from where the placenta is detached. This bleeding is stopped by effective contraction of the uterus. Bleeding after delivery may continue for about a month but becomes lesser in amount and pinkish in the later days. It consists of blood and shedding of the uterine lining. Excessive post delivery bleeding is an important clinical situation which can have some serious consequences on the health of the woman if not managed properly at the right time. It can occur either after a vaginal birth or following cesarean section.
In medical terms Post delivery bleeding has been defined as excessive if the blood loss following vaginal delivery is more than 500ml or in case of C Section more than 1 Litre. But sometimes blood loss even less than this cut off may be poorly tolerated by the mother if she is anemic. It is a clinical emergency which has to be dealt with immediately in the form of fixed protocol. This is defined as PPH(Post Partum Haemorrhage) drill which has to be followed by the attending obstetrician along with the team members.
There can be different causes of excessive bleeding after delivery which can be according to the time period of presentation after delivery. Excessive bleeding within 24 hours of delivery is called primary postpartum hemorrhage or bleeding. If it occurs after 24 hrs till 6 weeks of delivery it is known as secondary hemorrhage or bleeding. Immediately after delivery of the baby, the uterus starts contracting and retracting,the placenta separates and the natural process of contracting of the uterus stops the bleeding. For the uterus to contract effectively, the placenta should be completely removed. If the uterus is contracted properly then trauma to genital organs has to be ruled out like uterus, cervix and vagina or from episiotomy. Sometimes there may be a delay in the delivery of placenta which may be more than 1hour leading to excessive bleeding. Post delivery bleeding after 24hours of delivery is usually due to infection in uterus or other parts of genital tract. It may also be due to retained bits of placenta or membranes.
There are other causes that intensify the bleeding post delivery such as presence of coagulation defects, multiple pregnancy, excessive liquor, pre existing anaemia, preence of uterine fibroids, uterine malformation or prolonged labour. Also infection due to prolonged leaking is a contributing factor.
MANAGEMENT
Management of post delivery bleeding involves an aggressive approach which includes resuscitation of the compromised mother and also to find out the cause of bleeding. This involves oxygen administration, bimanual massage of uterus, immediate intravenous fluid administration and certain injections to contract the uterus which can stop the bleeding. If the blood loss is excessive, the woman might need blood transfusion. If the bleeding persists even after massage and injections then there may be some retained placental tissue or there might be a traumatic cause for which the patient needs to be shifted to the operating room and complete exploration of the genital tract is required by an expert and experienced assistants for evidence of any injury. Any laceration or tear can be repaired and one should look out for any blood collection(hematoma).
CONSEQUENCES
Excessive bleeding after delivery is an important cause of maternal morbidity and mortality worldwide. It is taking a high toll especially in the rural population due to lack of proper care during pregnancy and delivery. Absence of blood transfusion facilities and ignorance of illiterate women are contributing factors. Excessive bleeding may cause infection, blood transfusion reactions, thrombosis and failed lactation. Late complication may be a deficiency of hormones due to deficient blood supply to pituitary gland during shock.
PREVENTION OF POST DELIVERY BLEEDING
It is very important that one is in good health at time of delivery. Proper attention should be paid to nutrition and a balanced diet should be taken daily. Also green leafy vegetables and fruits should be included. Apart from this, one should take all the supplements prescribed to her especially iron tablets. During antenatal period one should get her hemoglobin checked frequently and any deficiency should be treated.
High risk pregnancies should be delivered at a tertiary centre. In cases of previous caesarean delivery the chances of adherent placenta increase so any USG showing the likelihood of adherent placenta must be followed by an MRI and a senior obstetrician should be involved.