Vaginal bleeding after childbirth

Vaginal bleeding in excess of 500 mL after childbirth is defined as postpartum haemorrhage (PPH). There are, however, some problems with this definition: 

• Estimates of blood loss are notoriously low, often half the actual loss. Blood is mixed with amniotic fluid and sometimes with urine. It is dispersed on sponges, towels and linens, in buckets and on the floor.

• The importance of a given volume of blood loss varies with the woman’s haemoglobin level. A woman with a normal haemoglobin level will tolerate blood loss that would be fatal for an anaemic woman.

Even healthy, non-anaemic women can have catastrophic blood loss. 

• Bleeding may occur at a slow rate over several hours and the condition may not be recognized until the woman suddenly enters shock.

Risk assessment in the antenatal period does not effectively predict those women who will have PPH. Active management of the third stage should be practiced on all women in labour since it reduces the incidence of PPH due to uterine atony . All postpartum women must be closely monitored to determine those that have PPH.

PROBLEMS

• Increased vaginal bleeding within the first 24 hours after childbirth (immediate PPH).

• Increased vaginal bleeding following the first 24 hours after childbirth (delayed PPH).

Continuous slow bleeding or sudden bleeding is an emergency; intervene early and aggressively. 

GENERAL MANAGEMENT

• SHOUT FOR HELP. Urgently mobilize all available personnel.

• Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature). 

• If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.

• Massage the uterus to expel blood and blood clots. Blood clots trapped in the uterus will inhibit effective uterine contractions.

• Give oxytocin 10 units IM.

• Start an IV infusion and infuse IV fluids.

• Catheterize the bladder.

• Check to see if the placenta has been expelled and examine the placenta to be certain it is complete (Table S-7). 

• Examine the cervix, vagina and perineum for tears.

• After bleeding is controlled (24 hours after bleeding stops), determine haemoglobin or haematocrit to check for anaemia:

- If haemoglobin is below 7 g/dL or haematocrit is below 20% (severe anaemia):

- Give ferrous sulfate or ferrous fumerate 120 mg by mouth PLUS folic acid 400 mcg by mouth once daily for 3 months;

- After 3 months, continue supplementation with ferrous sulfate or ferrous fumerate 60 mg by mouth PLUS folic acid 400 mcg by mouth once daily for 6 months.

- If haemoglobin is between 7–11 g/dL, give ferrous sulfate or ferrous fumerate 60 mg by mouth PLUS folic acid 400 mcg by mouth once daily for 6 months;

- Where hookworm is endemic (prevalence of 20% or more), give one of the following anthelmintic treatments:

- albendazole 400 mg by mouth once;

- OR mebendazole 500 mg by mouth once or 100 mg two times per day for 3 days; 

- OR levamisole 2.5 mg/kg body weight by mouth once daily for 3 days;

- OR pyrantel 10 mg/kg body weight by mouth once daily for 3 days.

- If hookworm is highly endemic (prevalence of 50% or more), repeat the anthelmintic treatment 12 weeks after the first dose.
　

DIAGNOSIS

TABLE S-7 Diagnosis of vaginal bleeding after childbirth 

^a Bleeding may be light if a clot blocks the cervix or if the woman is lying on her back.
^b There may be no bleeding with complete inversion.

MANAGEMENT

ATONIC UTERUS

An atonic uterus fails to contract after delivery.
　

• Continue to massage the uterus.

• Use oxytocic drugs which can be given together or sequentially (Table S-8).

TABLE S-8 Use of oxytocic drugs 

  Prostaglandins should not be given intravenously. They may be fatal. 

• Anticipate the need for blood early, and transfuse as necessary.

• If bleeding continues:

- Check placenta again for completeness;

- If there are signs of retained placental fragments (absence of a portion of maternal surface or torn membranes with vessels), remove remaining placental tissue;

- Assess clotting status using a bedside clotting test.  Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

• If bleeding continues in spite of management above:

- Perform bimanual compression of the uterus (Fig S-4):

- Wearing high-level disinfected gloves, insert a hand into the vagina and form a fist;

- Place the fist into the anterior fornix and apply pressure against the anterior wall of the uterus;

- With the other hand, press deeply into the abdomen behind the uterus, applying pressure against the posterior wall of the uterus;

- Maintain compression until bleeding is controlled and the uterus contracts.

FIGURE S-4 Bimanual compression of the uterus 

- Alternatively, compress the aorta (Fig S-5): 

- Apply downward pressure with a closed fist over the abdominal aorta directly through the abdominal wall:

- The point of compression is just above the umbilicus and slightly to the left;

- Aortic pulsations can be felt easily through the anterior abdominal wall in the immediate postpartum period. 

- With the other hand, palpate the femoral pulse to check the adequacy of compression:

- If the pulse is palpable during compression, the pressure exerted by the fist is inadequate; 

- If the femoral pulse is not palpable, the pressure exerted is adequate;

- Maintain compression until bleeding is controlled.

FIGURE S-5 Compression of abdominal aorta and palpation of femoral pulse 

Packing the uterus is ineffective and wastes precious time. 

• If bleeding continues in spite of compression:

- Perform uterine and utero-ovarian artery ligation;

- If life-threatening bleeding continues after ligation, perform subtotal hysterectomy.

TEARS OF CERVIX, VAGINA OR PERINEUM

Tears of the birth canal are the second most frequent cause of PPH. Tears may coexist with atonic uterus. Postpartum bleeding with a contracted uterus is usually due to a cervical or vaginal tear.

• Examine the woman carefully and repair tears to the cervix or vagina and perineum.

• If bleeding continues, assess clotting status using a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests
coagulopathy.

RETAINED PLACENTA

There may be no bleeding with retained placenta. 

• If you can see the placenta, ask the woman to push it out. If you can feel the placenta in the vagina, remove it.

• Ensure that the bladder is empty. Catheterize the bladder, if necessary.

• If the placenta is not expelled, give oxytocin 10 units IM if not already done for active management of the third stage.

Do not give ergometrine because it causes tonic uterine contraction, which may delay expulsion. 

• If the placenta is undelivered after 30 minutes of oxytocin stimulation and the uterus is contracted, attempt controlled cord traction.

Note: Avoid forceful cord traction and fundal pressure as they may cause uterine inversion.

• If controlled cord traction is unsuccessful, attempt manual removal of placenta.

Note: Very adherent tissue may be placenta accreta. Efforts to extract a placenta that does not separate easily may result in heavy bleeding or uterine perforation which usually requires hysterectomy. 

• If bleeding continues, assess clotting status using a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

• If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics as for metritis.

RETAINED PLACENTAL FRAGMENTS

There may be no bleeding with retained placental fragments. 

When a portion of the placenta—one or more lobes—is retained, it prevents the uterus from contracting effectively. 

• Feel inside the uterus for placental fragments. Manual exploration of the uterus is similar to the technique described for removal of the retained placenta.

• Remove placental fragments by hand, ovum forceps or large curette.

Note: Very adherent tissue may be placenta accreta. Efforts to extract fragments that do not separate easily may result in heavy bleeding or uterine perforation which usually requires hysterectomy. 

• If bleeding continues, assess clotting status using a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

INVERTED UTERUS

The uterus is said to be inverted if it turns inside-out during delivery of the placenta. Repositioning the uterus should be performed immediately. With the passage of time the constricting ring around the inverted uterus becomes more rigid and the uterus more engorged with blood.

• If the woman is in severe pain, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM.

Note: Do not give oxytocic drugs until the inversion is corrected.

• If bleeding continues, assess clotting status using a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

• Give a single dose of prophylactic antibiotics after correcting the inverted uterus:

- ampicillin 2 g IV PLUS metronidazole 500 mg IV;

- OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.

• If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics as for metritis.

• If necrosis is suspected, perform vaginal hysterectomy. This may require referral to a tertiary care centre.

DELAYED (“SECONDARY”) POSTPARTUM HAEMORRHAGE

• If anaemia is severe (haemoglobin less than 7 g/dL or haematocrit less than 20%), arrange for a transfusion and provide oral iron and folic acid.

• If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics as for metritis.

Prolonged or delayed PPH may be a sign of metritis. 

• Give oxytocic drugs (Table S-8).

• If the cervix is dilated, explore by hand to remove large clots and placental fragments. Manual exploration of the uterus is similar to the technique described for removal of the retained placenta.

• If the cervix is not dilated, evacuate the uterus to remove placental fragments.

• Rarely, if bleeding continues, consider uterine and utero-ovarian artery ligation or hysterectomy.

• Perform histologic examination of curettings or hysterectomy specimen, if possible, to rule out trophoblastic tumour.