Postpartum Haemorrhage (PPH)
Postpartum Haemorrhage (PPH)
It is normal to bleed after giving birth. It’s a combination of mucus, blood and tissue from the uterus and typically lasts around 4 - 6 weeks, reducing over time.
Some people experience heavier bleeding after birth and this is called a postpartum haemorrhage (PPH).
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 a combination).
The definition of PPH is quite arbitrary when you consider each person on an individual basis. The quantity is a visual estimation which is susceptible to human error, 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 for PPH 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 surges, or because of drugs used during labour.
PPH can also happen as a result 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 as a result of instrumental birth (forceps or ventouse), episiotomy (a cut to the perineum) or tearing, though this rarely leads to a PPH. 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), emptying the bladder and controlled cord traction of the placenta has not yet been birthed.
If heavy bleeding continues you may be taken to theatre.
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 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.
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, 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 matters and if you feel ultimately very safe in a hospital environment that is important.
After birth you will be offered a synthetic oxytocin injection into the thigh to encourage the uterus to contract down to birth the placenta. This could be combined with controlled cord traction (gentle pulling of the cord) and manual pressure to the lower stomach.
This is called a managed third stage or active management and it is your choice whether or not to accept.
Some stats for comparison
Managed third stage
· Routine use of drugs
· Deferred clamping and cutting of the cord (no earlier than 1 minute but not longer than 5 minutes as standard to facilitate controlled cord traction- you have the right to ask this to be after 5 minutes)
· Controlled cord traction after signs of separation of the placenta
· Shortens the third stage compared to physiological third stage
· Associated with nausea and vomiting in about 100 in 1000 people.
· Associated with an approximate risk of 13 in 1000 of haemorrhage of more than 1 litre of blood
· Associated with an approximate risk of 14 in 1000 of blood transfusion.
Physiological third stage
No routine of drugs
No clamping of the cord until pulsation has stopped and the cord goes white and limp
Delivery of the placenta by maternal effort
Associated with nausea and vomiting in about 50 in 1000 people
Associated with an approximate risk of 29 in 1000 of haemorrhage of more than 1 litre of blood
Associated with an approximate risk of 40 in 1000 of a blood transfusion
- NICE Pathway: Intrapartum care 2021. Care in third stage of labour
Most hospitals will regard anything longer than 30-60 minutes to birth the placenta to be “prolonged” although the choice is with you to decline the offer of active managed or transfer to theatre.
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 (forceps, ventouse) or episiotomy (a cut).
As much as possible it is better to be off your back in upright, forward and open (UFO) 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.
Regular intake of food is recommended in labour, although you may be told you can’t after an induction, which is a flagrant abuse of your basic human rights – strong advocacy required here). 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. Try a jar of honey and a spoon, Haribo sweets or glucose/energy tablets.
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 an increased 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 a number of 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, than 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.
Ford et al. (2007) Postpartum haemorrhage occurrence and recurrence: a population-based study. AMJ.
Oberg et al. (2012) Patterns of recurrence of postpartum haemorrhage in a large population-based cohort. AJOG.