Postpartum Haemorrhage

Definition and Classification of Postpartum Haemorrhage

Postpartum haemorrhage remains a leading cause of maternal morbidity and mortality across Nigeria. Clinically, it is defined as blood loss exceeding 500 mL following a vaginal birth, or greater than 1,000 mL after a caesarean section, within the first twenty-four hours postpartum. When bleeding occurs after the first twenty-four hours up to six weeks postnatal, it is classified as secondary postpartum haemorrhage.

Classification helps estimate severity and guide urgent interventions:

• Primary PPH: Heavy bleeding occurring within the first 24 hours of delivery, predominantly caused by uterine atony.
• Secondary PPH: Bleeding occurring from 24 hours up to 12 weeks postpartum, often linked to retained products of conception or subinvolution.
• Minor PPH: Total blood loss between 500 mL and 1,000 mL with no clinical signs of shock.
• Major PPH: Blood loss exceeding 1,000 mL, or any blood loss accompanied by hemodynamic instability.

A common clinical error is underestimating blood loss on delivery pads or wrappers, as amniotic fluid mixes with blood and traditional delivery suites in resource-limited settings often lack quantitative collection drapes.

The 4 Ts of Postpartum Haemorrhage

To systematically diagnose and treat postpartum haemorrhage, clinicians use the mnemonic representing the four primary causes: Tone, Tissue, Trauma, and Thrombin.

• Tone: Uterine atony is responsible for roughly seventy percent of all cases. Failure of the myometrium to contract effectively leaves open spiral arteries bleeding freely at the placental site.
• Tissue: Retained placental fragments or membranes prevent effective uterine contraction and closure of blood vessels.
• Trauma: Lacerations of the cervix, vagina, or perineum, along with uterine rupture or inversion, account for significant surgical bleeding.
• Thrombin: Pre-existing or acquired coagulation disorders, such as severe pre-eclampsia, abruptio placentae, or disseminated intravascular coagulation, impair clot formation.

Risk Factors and Clinical Recognition

Identifying antenatal and intrapartum risk factors allows midwives and nurses to prepare for potential emergencies before delivery occurs. Multiparity, polyhydramnios, macrosomia, prolonged labour, and a personal history of postpartum haemorrhage significantly elevate risk.

Early clinical recognition depends on close monitoring of vital signs. A drop in blood pressure is a late sign of shock because pregnant women compensate through increased blood volume and heart rate. Tachycardia and narrowed pulse pressure often appear long before overt hypotension manifests.

Prevention and Active Management of the Third Stage

Active management of the third stage of labour actively reduces the incidence of postpartum haemorrhage compared to physiological management. This evidence-based routine package consists of three core components:

1. Uterotonic administration: Injecting oxytocin intramuscularly or intravenously within one minute of fetal delivery. Oxytocin remains the first-line uterotonic due to its efficacy and minimal side effects.
2. Controlled cord traction: Applying gentle traction on the umbilical cord while simultaneously counter-applying pressure on the suprapubic area of the uterus.
3. Uterine massage: Massaging the uterine fundus immediately after placental delivery to stimulate sustained myometrial contraction.

Where oxytocin is unavailable or thermally degraded due to poor cold-chain storage in remote Nigerian primary healthcare centres, alternative uterotonics like misoprostol tablets are administered sublingually or orally.

Emergency Medical and Surgical Management

When heavy bleeding occurs, a coordinated multidisciplinary team approach is vital. Medical resuscitation starts with calling for help, securing large-bore intravenous access, and infusing warmed crystalloid fluids. Uterotonic medications are escalated stepwise: oxytocin infusion, ergometrine, and carboprost or misoprostol.

If medical management fails to control uterine atony, surgical interventions must be deployed promptly:

• Bimanual compression: Compressing the uterus between a fist in the vagina and a hand on the abdominal wall.
• Uterine balloon tamponade: Inserting a hydrostatic catheter into the uterine cavity to apply direct pressure against bleeding sinusoids.
• Surgical sutures: Applying compression sutures like the B-Lynch technique.
• Devascularization or Hysterectomy: Ligation of uterine or ovarian arteries, or performing a subtotal or total hysterectomy as a life-saving measure of last resort.

Nursing Care, Resuscitation, and Complications

Nursing management during a severe postpartum haemorrhage requires rapid task delegation, continuous monitoring, and emotional reassurance for the mother and her family. The nurse must insert an indwelling urinary catheter with a urometer to accurately measure hourly urine output, serving as a sensitive indicator of renal perfusion.

Blood transfusion protocols must be initiated early when blood loss is massive. Nurses monitor for transfusion reactions, document total fluid input and output strictly, and ensure warmth using blankets to prevent hypothermia, which exacerbates coagulopathy.

Long-term complications of severe postpartum haemorrhage include Sheehan's syndrome resulting from ischemic necrosis of the anterior pituitary gland, chronic iron-deficiency anaemia, psychological trauma, and increased risk of haemorrhage in subsequent pregnancies.