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PPH (postpartum haemorrhage)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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This is bleeding from the genital tract after the delivery of a baby.

It can be broadly divided into primary and secondary types, the distinction being the timing of the onset of the bleed relative to the delivery (1,2).

A primary postpartum haemorrhage is a loss (usually defined as more than 500ml) in the first 24 hours after delivery.

It is important to note that in pregnancy the clinical parameters may be unreliable; for example, apparent normotension can be due to pre-eclampsia combined with blood loss.

Postpartum bleeding - Postnatal Care (3)

Discuss with women what vaginal bleeding to expect after the birth (lochia), and advise women to seek medical advice if:

  • the vaginal bleeding is sudden or very heavy
  • the bleeding increases
  • they pass clots, placental tissue or membranes
  • they have symptoms of possible infection, such as abdominal, pelvic or perineal pain, fever, shivering, or vaginal bleeding or discharge has an unpleasant smell
  • they have concerns about vaginal bleeding after the birth

If a women seeks medical advice about vaginal bleeding after the birth, assess the severity, and be aware of the risk factors for postpartum haemorrhage

  • Antenatal risk factors:
  • previous retained placenta or postpartum haemorrhage
  • maternal haemoglobin level below 85 g/litre at onset of labour
  • BMI greater than 35 kg/m2
  • grand multiparity (parity4 or more)
  • antepartum haemorrhage
  • overdistention of the uterus (for example, multiple pregnancy, polyhydramnios or macrosomia)
  • existing uterine abnormalities
  • low-lying placenta
  • maternal age of 35 years or older.
  • Risk factors in labour:
  • induction
  • prolonged first, second or third stage of labour
  • oxytocin use
  • precipitate labour
  • operative birth or caesarean section

Also be aware of the following factors, which may worsen the consequences of secondary postpartum haemorrhage:

  • anaemia
  • weight of less than 50 kg at the first appointment with the midwife during pregnancy (booking appointment).

Prevention of postpartum haemorrhage (2):

  • traditionally, oxytocin and ergot preparations have been used as uterotonic agents for postpartum haemorrhage prophylaxis mostly as part of active management of the third stage of labour
    • a major disadvantage, mainly related to ergot preparations, is the relatively high incidence of side-effects such as nausea, vomiting and increase in blood pressure
  • misoprostol may prevent severe postpartum haemorrhage but the evidence is inconsistent
    • misoprostol or intramuscular postaglandins are not more effective than conventional injectable uterotonics - both lead to more adverse effects
    • the review concludes that neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.


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