Postpartum Bleeding

Postpartum Bleeding

Postpartum hemorrhage is bleeding that occurs for several weeks after giving birth. This bleeding can be normal, it can also be abnormal. Abnormal postpartum hemorrhage is the main cause of maternal death during childbirth.

Under normal conditions, blood that comes out of the vagina after giving birth is called lochia or puerperal blood . Lochia occurs due to the collapse of uterine tissue that forms during pregnancy.

In addition to blood in the form of lochia which is normal, some women can experience abnormal postpartum bleeding. In medical terms, this condition is called postpartum hemorrhage .

Abnormal postpartum bleeding needs to be treated as soon as possible because it has the potential to cause serious complications, and can even cause death in the woman giving birth.

Causes of Postpartum Bleeding

During labour, the uterine muscles naturally contract and push the placenta out of the uterus. After the placenta has succeeded in coming out, contractions in the uterus aim to stop bleeding by pressing the blood vessels in the uterine wall where the placenta (placenta) was attached.

In normal bleeding, the blood will gradually decrease and eventually stop within a few weeks after delivery. However, if there is interference, bleeding can continue to occur and the amount is excessive.

Based on the cause, abnormal postpartum hemorrhage is divided into two types, namely primary and secondary postpartum hemorrhage. The explanation is as follows:

Primary postpartum hemorrhage  

Primary postpartum hemorrhage occurs within the first 24 hours after delivery. Generally, this bleeding is caused by a weak uterine muscle (uterine atony), but it can also be due to retained placenta , lacerations to the uterus, cervix, or vagina, and blood clotting disorders.

Secondary postpartum hemorrhage

Slightly different from primary bleeding, secondary postpartum hemorrhage occurs after 24 hours to 6 weeks postpartum. Generally, this condition is caused by an infection in the uterus ( endometritis ), which is the most common cause of death in women giving birth.

Apart from endometritis, retained placenta and amniotic sac remaining in the uterus can also cause secondary postpartum hemorrhage. This is because the placenta or amniotic sac that remains in the uterus can prevent the uterus from contracting normally to stop bleeding.

There are several factors that put women at risk for abnormal postpartum bleeding, namely:

  • Have a history of bleeding in a previous pregnancy
  • Are overweight or obese
  • Be over 40 years old at the time of delivery
  • Give birth to twins
  • Experiencing placenta previa
  • Suffer from preeclampsia
  • Experiencing anemia during pregnancy
  • Undergo labor by caesarean section
  • Undergoing labor by induction
  • Undergo labor for more than 12 hours
  • Give birth to babies weighing over 4 kilograms

Postpartum Bleeding Symptoms

Normal postpartum bleeding is characterized by the discharge of bright red blood lochia which within a few days after delivery will turn pink and brown. Generally, this bleeding will stop gradually within 3-6 weeks.

Postpartum bleeding is called abnormal if the blood that comes out is more than 500 milliliters in women who have normal deliveries or more than 1,000 ml in women who have deliveries by caesarean section .

Blood that comes out in abnormal postpartum hemorrhage is generally accompanied by the release of blood clots that can be larger than a golf ball in size. Women who experience abnormal bleeding may also experience some of the following symptoms:

  • Dizzy, like going to faint
  • Weak
  • Heart beat
  • Hard to breathe
  • Sweating
  • Restless or confused
  • Fever
  • Abdominal pain
  • Blood smells bad
  • Pelvic pain
  • Pain when urinating

Be aware of these symptoms, especially when accompanied by a drop in blood pressure. The reason is, it can be a sign of imminent hypovolemic shock which can be life threatening.

When to see a doctor

Call your doctor if the bleeding is severe enough, marked by filling the pads in less than 1 hour, or if the bleeding doesn't subside after a few days.

Examination also needs to be done if you experience the following symptoms:

  • Signs of infection appear , such as smelly discharge from the vagina or surgical wound, chills, and fever to a body temperature above 38oC
  • The blood that comes out is bright red and thick in the second week
  • One or both sides of the abdomen feel tender
  • Dizziness or feeling like fainting
  • Irregular and fast heartbeat
  • Blood clots that come out very large or a lot

Seek medical help immediately if the blood that comes out is so large that it causes symptoms of shock, such as:

  • Headache
  • Limp body
  • pounding heart ( palpitations )
  • Hard to breathe
  • Sweating
  • Nervous
  • Confused or dazed

Diagnosis of Postpartum Hemorrhage

Postpartum bleeding requires a quick diagnosis, so usually an obstetrician will start the diagnosis process with a physical examination.

During a physical examination, if the birth canal is still open, the doctor may insert his fist into the patient's uterus to feel the strength of the uterine muscles and check whether there is still a retained placenta or tear in the uterus.

If the physical examination is not enough to determine the cause of postpartum bleeding, supporting examinations, such as pelvic ultrasound , can be carried out to see the source of the bleeding.

Blood tests can also be done to determine the possibility of blood clotting disorders and to estimate the amount of blood lost for blood transfusion needs .

Treatment of Postpartum Hemorrhage

The first thing a doctor will do to treat postpartum hemorrhage is to save the patient's life, especially if hypovolemic shock occurs. The reason is, shock can make the body's organs work to stop quickly.

Doctors can give intravenous fluids or blood transfusions to replace lost blood. After the patient's condition is stable, the doctor will try to control the bleeding according to the cause.

The following are some of the methods doctors can use to treat postpartum hemorrhage:

  • Massaging the uterus
    If bleeding occurs because the uterine muscles are weak, the doctor will massage the patient's uterus to stimulate contractions, so that the bleeding can stop. Doctors can also give oxytocin or methylergometrine drugs to trigger uterine contractions. Giving oxytocin can be done rectally, intravenously, or injected directly into the muscle.
  • Pressing blood vessels with a special balloon.
    If bleeding is caused by a torn wound, the doctor can insert gauze or a balloon which is then inflated in the uterus. The goal is that the blood vessels where the bleeding occurs are compressed, so that the blood can stop coming out.
  • Removing the remaining placental tissue with a curettage
    . For cases of bleeding that occur due to placental tissue remaining in the uterus (placental retention), the doctor can perform a curette procedure to remove the tissue.
  • Prescribing antibiotics
    In cases of postpartum hemorrhage due to infection, treatment will be carried out with antibiotics.

If the bleeding has not stopped, the doctor can perform surgery. In some cases, embolization or occlusion surgery may be performed to stop the bleeding. If necessary, surgical removal of the uterus or hysterectomy may be recommended , although this is rarely done.

After the bleeding has stopped, the patient needs to be hospitalized for full monitoring until his condition is declared stable. If necessary, the patient will be treated in the ICU .

Monitoring carried out includes measuring pulse, blood pressure, respiratory rate, body temperature, and the amount of urine that comes out, as well as a complete blood count . Monitoring is not only done after the bleeding has stopped, but from the start on a regular basis while the doctor is trying to stop the bleeding.

Postpartum Hemorrhagic Complications

Postpartum bleeding can cause serious complications, namely:

  • Hypovolemic shock
  • Disseminated intravascular coagulation (DIC), namely blood clots that are widespread throughout the body
  • Acute kidney failure
  • Acute respiratory distress syndrome
  • Failure to function in various organs of the body, either due to shock or DIC
  • Dead

Prevention of Postpartum Bleeding

Keep in mind, postpartum bleeding can be normal, but it can also be abnormal. Given that abnormal bleeding can be caused by many things, it is difficult to completely prevent this condition from occurring.

The best effort that can be done is to routinely check the womb to the obstetrician. That way, doctors can find out whether you are at risk for abnormal bleeding, so doctors can provide and prepare treatment before, during, and after delivery.

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