Everything Women Need to Know About Post-partum Haemorrhage - Prof Dr Suchitra N. Pandit

Understanding Post-partum Haemorrhage

Parenthood is a remarkable and joyous journey, but it also has its share of obstacles, including potential complications such as post-partum haemorrhage (PPH). Post-partum haemorrhage (PPH) refers to excessive bleeding after childbirth, leading to a devastating and deadly situation.

According to the WHO, each year millions of women experience PPH, within 24 hours after giving birth to a child. It is a synchronized reaction that occurs within 24 hours following the delivery of a child. More than 14 million women throughout the globe contract PPH. It is a major cause of maternal morbidity up to 70,000 individuals die each year. Therefore, it is crucial that expecting parents are well-versed in PPH to be able to navigate this aspect of childbirth effectively.

In many cases, there are limited early warning signs. The initial stages of PPH does not show noticeable symptoms, making it challenging to identify and intervene in a timely manner. The post-partum period brings along a lot of symptoms like fatigue, tiredness, or weakness.

Due to the lack of knowledge, women often tend to ignore the early signs, assuming they are part of the expected post-birth experience. Women with pre-existing health conditions, such as anaemia or blood clotting disorders, may be at a higher risk for PPH.

These conditions can further complicate the body's ability to respond effectively to excessive bleeding. Due to lack of awareness or misinterpretation of symptoms, there might be a delay in recognizing the severity of the situation. The health of both- mother and the baby can be posed to high risk, if there is a delay in seeking medical attention or initiating appropriate treatment interventions.

According to the National Health Mission, In India, 38% of women who succumb during childbirth go through heavy bleeding after delivery. PPH can happen to about 3-5% of women in their first pregnancy, and the risk goes up to 4-5% in later pregnancies.

Post-partum Haemorrhage: Understanding the Underlying Factors

Anaemia plays a substantial role in contributing to post-partum haemorrhage (PPH). Women with anaemia are unable to endure even a small amount of blood loss in comparison to healthy women, as anaemia reduces the oxygen-carrying capacity of blood.

Their ability to clot effectively decreases, and they become susceptible to excessive bleeding. Globally, a staggering 37% of pregnant women and 30% of women aged 15–49 grapple with anaemia.

According to a The Lancet report, a 6.2% risk of clinical post-partum haemorrhage in women with moderate anaemia and an 11.2% risk in those with severe anaemia. In India, recent data from 2021 reveals that 13.98% of non-pregnant women and 26.66% of pregnant women suffer from severe or moderate anaemia.

While PPH can occur after any childbirth, there is an increased risk with subsequent deliveries. Mothers who have experienced post-partum haemorrhage (PPH) in their previous deliveries face significantly elevated risks in subsequent pregnancies. Specifically, the study found that these mothers had a threefold higher risk of PPH in their second delivery and a sixfold higher risk in their third delivery.

While PPH typically occurs following placental delivery, it can also occur at a later stage. Given the increase in the prevalence of C-sections in India, rising from 17.2% in 2016 to 21.5% in 2021, there has been a corresponding escalation in the burden of PPH in the country.

Effective management of many risk factors can be achieved with high-quality prenatal care, including access to ultrasound services, in addition to close observation during the post-partum period. Early detection and treatment are critical in the event of bleeding.

PPH Safeguard: Strategies for Prevention

A comprehensive approach that emphasizes both prevention and management is required to address the issue of PPH, effectively. Through proactive targeting risk factors and ensuring immediate access to appropriate treatments, maternal well-being can be enhanced during the critical post-partum period.

For the management of third stage of labour, use of utero tonics Oxytocin, uterine massage and controlled cord traction, all maternity units should have trained healthcare staff. They should be trained enough to monitor patients carefully, after giving birth, assess the amount of blood loss, and identify which patients having continuous bleeding.

Seeking immediate help should be considered as the first and foremost step in case of any woman experiencing abnormal blood loss due to excessive bleeding. This method is referred as the Bundle approach.

However, many healthcare units are not well-equipped with enough staff or essential resources, like life-saving medications like oxytocics and tranexamic acid, or blood products for transfusions. FOGSI, in collaboration with the Government of India, has been instrumental in creating guidelines and providing training to healthcare workers at all levels of healthcare.

According to the WHO, addressing existing deficiencies, including recommendations related to mitigating antenatal and intrapartum risk factors associated with post-partum haemorrhage (PPH) can reduce the burden of PPH in India.

This includes things like treating and preventing anaemia, identifying placentas that are abnormally positioned (praevia) or morbidly adherent (accreta), enhancing the precision of PPH detection techniques (including blood loss measurement), and streamlining referral, transportation, and task-sharing processes, among other aspects of health systems.

PPH Management

Early diagnosis and intervention is extremely important in effective management of Post-partum Haemorrhage (PPH) in the form of a structured bundle approach. The E-MOTIVE intervention comprises three key elements: an early detection strategy, the initiation of the "MOTIVE" first-response bundle based on WHO guidelines and seeking assistance.

The "MOTIVE" bundle consists of:

• M: Uterine massage
• O: Oxytocics (oxytocin, methylergonovine, carboprost, or misoprostol)
• T: Tranexamic acid
• I: IV fluids
• E: Examination of the genital tract with a plan for escalating treatment if PPH persists
• There are new treatments available to address the serious issue of maternal mortality and severe maternal complications. In some locations in South India, vacuum-induced suction, using a metal suction cannula, has been successfully attempted. Global research has shown that the Jada System, a device utilizing vacuum to control bleeding, is efficient in quickly managing abnormal post-partum uterine bleeding and post-partum haemorrhage. This system is reported to be easy to use, has a short treatment duration, and causes less trauma as it is made of silicone. The advantage of vacuum-induced control is that it prompts the muscles to return to their normal contraction, stopping the bleeding.
• Utero tonics: Uterine massage is recommended for the treatment of PPH as soon as it is diagnosed. If utero tonics are not available, or if the patient does not respond to standard first line treatments (utero tonic drugs, tranexamic acid, intravenous fluids), the use of conservative measures, including uterine balloon tamponade, may be attempted in order to avoid the need for surgical intervention.
• Uterine balloon tamponade - To treat post-partum haemorrhage (PPH), doctors may use a uterine balloon tamponade if other first line treatments are ineffective. This involves inserting a balloon into the uterus to apply pressure and stop the bleeding.
• Blood transfusions: Another important treatment for managing PPH is blood transfusions, which replace the blood that has been lost and helps to stabilize mother's health. Blood transfusion helps in reducing maternal mortality and is considered as the main component of emergency obstetric care.