Definition

Postpartum hemorrhage, also known in English as postpartum hemorrhage, is severe bleeding that occurs within 24 hours to 12 weeks after childbirth. The earlier the bleeding is detected, the better the treatment outcomes will be.

There are two types of postpartum hemorrhage based on the time of occurrence:

• Early postpartum hemorrhage, which occurs within the first 24 hours after the placenta is delivered.
• Secondary postpartum hemorrhage, which occurs during the postpartum period and does not include the first 24 hours after the placenta is delivered.

A mother is considered to be experiencing postpartum hemorrhage if she loses:

• More than 500 ml of blood during normal delivery (vaginal delivery); or
• More than 1000 ml of blood during a cesarean section.

Bleeding of this volume can cause disturbances in vital signs (blood pressure, pulse rate, respiratory rate, temperature) in the mother. In Indonesia, the maternal mortality rate remains quite high, with most deaths caused by postpartum hemorrhage. Compared to other ASEAN countries, maternal deaths due to postpartum hemorrhage in Indonesia remain the highest.

Postpartum hemorrhage continues to be a complex issue globally. In addition to Indonesia and ASEAN countries, the postpartum hemorrhage rate remains high in sub-Saharan Africa. Worldwide, postpartum hemorrhage occurs in 1-10% of all deliveries.

Causes

There are four factors associated with postpartum hemorrhage:

Uterine Muscle Tone

Tone refers to the amount of tension or resistance in a muscle that is relaxing. For example, in joint muscles, tone can be felt when you perform passive stretching while the muscle is at rest.

After the baby is born, the uterus continues to contract to expel the placenta. These contractions also help to compress the blood vessels where the placenta attaches to the uterus. Therefore, if the uterine muscles lose their ability to contract after delivery, continuous bleeding will occur. This condition is known as uterine atony and is the most common cause of postpartum hemorrhage.

Placental Tissue

If the placental tissue cannot separate from the uterine wall due to placental adhesion, it will affect the uterus's ability to contract after delivery and stop the bleeding. Placenta deeply embedded in the uterus can cause life-threatening postpartum hemorrhage.

Trauma

Trauma refers to injuries causing bleeding in areas such as:

• Vagina
• Cervix
• Uterus
• Perineum (the sensitive area between the genitals and anus)

Postpartum hemorrhage can also occur if part of the placenta remains attached to the uterine wall. Additionally, the use of medical instruments like forceps and vacuum devices to assist in delivery can increase the risk of postpartum hemorrhage.

Thrombin

Thrombin is a substance in the body that plays a role in the blood clotting process. When there are pregnancy-related issues such as eclampsia (a condition where high blood pressure during pregnancy leads to seizures or coma), it can affect thrombin's ability to clot blood. As a result, bleeding becomes difficult to stop.

If you are interested in knowing more about eclampsia, you can read it here: Eclampsia - Definition, Cause And Risk Factor.

Risk Factor

Medical conditions that can increase the risk of postpartum hemorrhage include:

• Placental disorders
• Abruptio placentae, where the placenta detaches from the uterus before delivery
• Placenta previa, where the placenta covers part or all of the birth canal, making delivery difficult
• The placenta deeply attaches to the uterine tissue, causing it to be difficult to detach after delivery
• Uterus excessively enlarged beyond normal size during pregnancy, usually experienced by mothers with large fetuses
• Multiple pregnancies or carrying more than one fetus
• Experiencing high blood pressure or preeclampsia (high blood pressure and protein in the urine) during pregnancy.
• History of multiple pregnancies (five or more)
• Prolonged labor
• Anemia or infection
• Obesity, or being overweight
• Use of certain medications, such as those to stimulate labor or stop contractions (in premature labor)
• Use of medical instruments like forceps or vacuum devices to assist in delivery
• Tears in the cervix or vagina

Symptoms

Symptoms of postpartum hemorrhage can be recognized starting from the first 24 hours after delivery and once the placenta has been expelled. In addition to persistent bleeding, the mother may experience symptoms such as:

• Symptoms of low blood pressure such as dizziness, chills, fainting, and blurred vision
• Increased heart rate
• Reduced red blood cell count
• Pale and cold skin
• Nausea or vomiting
• Severe abdominal or pelvic pain

Be honest with your healthcare provider about how you feel after delivery. In some cases, postpartum hemorrhage may not cause any symptoms after you leave the hospital. Therefore, routine check-ups during the postpartum period are crucial. If there are signs of postpartum hemorrhage, the issue can be addressed promptly.

Diagnosis

Diagnosis of postpartum hemorrhage can be done through physical examination and additional tests after delivery.

Physical examination includes monitoring the mother within the first 24 hours postpartum by assessing vital signs such as:

• Blood pressure
• Body temperature
• Respiratory rate
• Heart rate
• Pain level

The doctor will also conduct a physical examination of the mother to ensure there are no complaints such as:

• Abdominal pain
• Pale skin
• Nausea and vomiting
• Chills
• Blurred vision, etc.

Laboratory tests, such as blood tests and clotting factor tests, may also be conducted. If the mother has lost more than 1.5 liters of blood, the doctor will determine the mother's blood type. In the laboratory, the mother's blood sample will be matched with the donor's blood for transfusion purposes.

Management

Since postpartum hemorrhage is an emergency condition, healthcare providers will first stabilize the patient's condition and manage the bleeding.

Management options include:

• Uterine massage to help the uterine muscles contract and stop the bleeding
• Administration of medications to stimulate uterine contractions
• Removal of any remaining placenta from the uterus
• Repair of injuries to the reproductive organs that occurred during delivery
• Stopping the bleeding in the uterus
• Blood transfusion

In some cases, if these methods are unsuccessful, the doctor may plan to perform laparotomy surgery to locate the source of bleeding in the abdomen. Hysterectomy or removal of the uterus may also be an option.

Recovery from postpartum hemorrhage varies depending on the severity and the amount of blood lost. Consuming a balanced diet, drinking plenty of fluids and water, and getting enough rest can speed up the recovery process. Healthcare providers may also prescribe iron supplements to prevent anemia and aid recovery.

Complications

Complications of postpartum hemorrhage that may occur include:

• Severe anemia
• Fatigue
• Postpartum depression
• Orthostatic hypotension, which is low blood pressure that occurs when standing after sitting or lying down for a long time
• Death, etc.

Prevention

The best way to prevent postpartum hemorrhage is by recognizing the risk factors that may arise during pregnancy and delivery. Regularly attend prenatal check-ups and provide complete information about your pregnancy and medical history to your healthcare provider.

Additionally, ensure that your red blood cell and iron levels are within normal limits during pregnancy to minimize the effects of postpartum hemorrhage.

You are also advised to meet your nutritional needs during pregnancy by:

• Eating nutritious foods
• Attending regular prenatal check-ups
• Reducing intake of high-salt, high-sugar, and high-fat foods during pregnancy
• Drinking plenty of water

When to See a Doctor?

Bleeding during pregnancy and delivery is an emergency, whether during pregnancy or the postpartum period. Therefore, seek medical help immediately if you experience bleeding from the genital area to receive appropriate treatment. Additionally, be honest about your condition and any complaints with the healthcare provider, especially during the first 24 hours after delivery.

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