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  • Writer's pictureLeanne

Postpartum Haemorrhage (PPH)- What do you actually need to know?

Once you have your baby, your body will contract to expel the placenta and that signifies to the body that the baby has been born and your body will release some blood- this is as the uterine wall constricts. It is absolutely normal to bleed after giving birth!

You’ll probably find that is it isn’t just blood that you lose, it’s a combination of mucus, blood and tissue from the uterus and typically lasts from a few days to 6 weeks, reducing over time. Some people experience heavier bleeding after birth however, and this is called a postpartum haemorrhage (PPH). Thi



s can be primary or secondary, so let’s look into a PPH a bit more!


What is a PPH?

Primary PPH is categorised as blood loss over 500ml within the first 24 hours. It can be considered ‘minor’ (500-1000ml) or ‘major’ (over 1000ml). The bleeding may come from the uterus, cervix, vagina or labia (or often a combination).

 

The definition of PPH is quite subjective when you consider each person on an individual basis. The quantity is a visual estimation which is susceptible to human error, we often can’t accurately measure blood loss, and everyone differs in the way their body copes with levels of blood loss. It is more important to consider the effect of the loss; one person may have little effect after losing 1000ml but another may feel extremely unwell after losing less than 500ml. Strangely, it is not considered PPH in a Caesarean until 1000ml, further evidence why a numerical estimate lacks accuracy.


What causes a PPH?

The most common reason is uterine atony which is when the uterus is not able to contract down after birth to close off blood vessels when the placenta has come away. This could be due to environmental factors interfering with oxytocin production, which is responsible for contractions, or because of drugs used during labour. It is why planning for the third stage is important.

PPH can also happen because of damage to the uterus such as during Caesarean and separation of tissue at the site of a previous Caesarean incision. Damage to the vagina or labia can happen because of instrumental birth, episiotomy or tearing, though this rarely leads to a PPH. Finally, a retained placenta can also lead to heavy bleeding.



What happens if I have a PPH?


In most cases simple measures will reduce heavy bleeding; the uterus can be stimulated to contract by massage or a synthetic oxytocin injection (or a second injection if you already had one for the third stage). If heavy bleeding continues you may be taken to theatre where the cause of the bleed will be identified and treated. In some cases, the use of a ‘Bakri balloon’ will be used to stop the bleed internally, and in extreme (and very low probability) a hysterectomy would be required. 


Reducing your chances of a PPH

The Birthplace Study (2011) showed that up to twice as many people experienced severe PPH if they planned to birth in hospital compared to those who planned to birth at home or in a midwife led unit. The data is for those classed as “low risk” but it we can assume that “high risk” people without a specific medical/personal circumstance increasing risk of bleeding in excess would be at lower risk of PPH if they planned to birth outside of a consultant led labour ward. Makes sense given the environment right?

Oxytocin is responsible for contractions to birth your baby, as well as for the uterus to contract down to cut off blood vessels after separation of the placenta. To release oxytocin, we need to feel protected and uninterrupted in an environment that is dimly lit and safe. Skin to skin with the newborn baby, allowing them to nuzzle or initiate breastfeeding, will help oxytocin production after the birth too.

Oxytocin is inhibited by a bright and unfamiliar. Fear/anxiety, feeling observed, and being moved or kept in a restricted position creates adrenaline which interrupts oxytocin. This is why place of birth is significant. Remember, however, that personal preferences matter as some people would actually feel more reassured and safer in a hospital environment.

After birth you will be offered a synthetic oxytocin injection to encourage the uterus to contract down to birth the placenta. This is called a managed third stage and it is your choice whether to accept, or not. It can reduce the risk of PPH but if you preferred to wait for the placenta to come naturally (a physiological third stage) you could opt to wait and if you did bleed heavily the injection is then available as a treatment for PPH.

Using positions that mean the baby can birth more easily will reduce the chances of tearing and reduce the likelihood of intervention such as instrumental birth or episiotomy. If it can be avoided, it is better to be off your back in upright, forward and open positions such as on all fours or kneeling/leaning over something such as a birth ball or the head of the bed.

Glucose is one of the main fuels for muscle activity in the uterus and exhaustion means the muscles can’t respond. If the uterus is depleted of glucose and has insufficient energy to contract it could result in PPH. This is why regular intake of food is recommended in labour but making sure energy levels are managed in later stages could reduce your risk of PPH by giving your uterus the glucose it needs to keep functioning. My favourite is honey- give it a try!


Am I at greater risk of a PPH if I have had one before?

Experiencing PPH in one birth does not mean PPH is inevitable next time. There is, however, a possible increase in likelihood of it happening, hence your care providers may recommend giving birth in a consultant led labour ward and having an actively managed third stage. However, it is dependent on several factors including the birth environment, the cause of the previous PPH and how accurately your first experience was diagnosed. Remember everyone reacts differently and quantifying it is inaccurate.

If your PPH was caused by a known event such as a tear, then it is no more likely to happen again. If your PPH happened after an induction and the cause was your uterus not reacting to drugs quickly enough, there is no reason to assume you will have another PPH if your next labour is spontaneous. Your body responds differently to the synthetic oxytocin of induction, when your oxytocin receptors may not be ready, then it does to natural oxytocin of spontaneous labour.



Around 15% of people experience PPH in a subsequent pregnancy having had one in their first (Ford et al, 2007 and Oberg et al., 2012) compared to around 5% of people having a first PPH in their first pregnancy. Over 20% were found to have a third consecutive PPH. The risk of PPH with subsequent pregnancies reduces if there has been no previous PPH at all.





My top tips:

·      Know your options for your third stage of labour.

·      Plan for your third stage.

·      Think about your birth choices and environment.



Ford et al. (2007) Postpartum hamorrhage occurrence and recurrence: a population-based study. AMJ.Oberg et al. (2012) Patterns of recurrence of postpartum hemorrhage in a large population-based cohort. AJOG.

 


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