Postpartum bleeding is bleeding that occurs for several weeks after delivery. This bleeding can be normal or abnormal. Abnormal postpartum hemorrhage is a major cause of maternal death during childbirth.
Under normal conditions, the 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 is formed during pregnancy.
In addition to the normal lochia blood, some women may experience abnormal postpartum bleeding. In medical terms, this condition is called postpartum hemorrhage.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 women who give birth.
Causes of Postpartum Bleeding
During labor, the uterine muscles naturally contract and push the placenta out of the uterus. After the placenta is successfully expelled, the uterine contractions aim to stop the bleeding by pressing the blood vessels in the uterine wall where the placenta was attached.
In normal bleeding, the blood will gradually decrease and eventually stop within a few weeks after delivery. However, if there is a disturbance, the bleeding may continue and be excessive in quantity.
Based on the cause, abnormal postpartum bleeding is divided into two types, namely primary and secondary postpartum hemorrhage. The explanation is as follows:
Primary postpartum haemorrhage
Primary postpartum hemorrhage occurs within the first 24 hours after delivery. Generally, this bleeding is caused by weak uterine muscles (uterine atony), but it can also be due to retained placenta, torn wounds to the uterus, cervix, or vagina, and blood clotting disorders.
Secondary postpartum haemorrhage
Slightly different from primary bleeding, secondary postpartum hemorrhage occurs after 24 hours to 6 weeks postpartum. Generally, this condition is caused by infection in the uterus (endometritis), which is the most common cause of death in childbirth.
In addition to endometritis, retention of the placenta and the remaining amniotic sac in the uterus can also cause secondary postpartum hemorrhage. The reason is, the placenta or amniotic sac that is still left in the uterus can make the uterus unable to contract 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
- Being overweight or obese
- Over 40 years of age at the time of delivery
- Giving birth to twins
- Having placenta previa
- Suffering from preeclampsia
- Experiencing anemia during pregnancy
- Having a cesarean delivery
- Undergoing induction
- Undergoing labor for more than 12 hours
- Give birth to a baby weighing more than 4 kilograms
Symptoms of Postpartum Bleeding
Normal postpartum bleeding is characterized by bright red lochia blood which in 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 a normal delivery or more than 1,000 ml in women who have a caesarean section.
Blood that comes out in abnormal postpartum bleeding is generally accompanied by the discharge of blood clots that can be larger than a golf ball. Women who experience abnormal bleeding may also experience some of the following symptoms:
- Dizzy, like fainting
- Heart beat
- Hard to breathe
- Restless or confused
- Stomach pain
- Blood stinks
- 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 hypovolemic shock that can be life-threatening.
When to go to the doctor
Call your doctor if the bleeding is severe enough, is indicated by a full dressing in less than 1 hour, or if the bleeding doesn't subside after a few days.
You will also need to be tested if you experience the following symptoms:
- Signs of infection appear, such as foul-smelling discharge from the vagina or surgical wound, chills, and fever up to body temperature above 38oC
- The blood that comes out is bright red and thick in the second week
- One or both sides of the stomach feel soft
- Dizziness or feeling like passing out
- Irregular heartbeat and accelerating
- Blood clots that come out very large or a lot
Seek immediate medical attention if the bleeding is profuse enough to cause symptoms of shock, such as:
- limp body
- Heart palpitations (palpitations)
- Hard to breathe
- Confused or dazed
Diagnosis of Postpartum Bleeding
Postpartum bleeding requires a quick diagnosis, so usually the 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 for retained placenta or tears in the uterus.
If the physical examination is not sufficient to determine the cause of postpartum bleeding, additional investigations, such as pelvic ultrasound, can be performed to determine the source of the bleeding.
Blood tests can also be done to determine the possibility of blood clotting disorders and estimate the amount of blood lost for the need for blood transfusions.
Postpartum Bleeding Treatment
The first thing a doctor will do to treat postpartum hemorrhage is action to save the patient's life, especially in the event of hypovolemic shock. The reason is, shock can make the body's organs stop working 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 methods that doctors can use to treat postpartum bleeding:
- Massaging the uterusIf the 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 the drug oxytocin to trigger uterine contractions. Oxytocin can be given rectally, intravenously, or injected directly into the muscle.
- Pressing blood vessels with special balloonsIf the bleeding is caused by a tear, the doctor may insert a gauze or balloon which is then inflated in the uterus. The goal is that the blood vessels at the site of bleeding are compressed, so that blood can stop coming out.
- Remove the remaining placental tissue with curettageFor cases of bleeding that occurs due to placental tissue that is still left in the uterus (placental retention), the doctor may perform a curettage to remove the tissue.
- Prescribing antibioticsIn cases of postpartum bleeding due to infection, the treatment will be done with antibiotics.
If the bleeding has not stopped, the doctor can perform surgery. In some cases, surgical embolization or blockage of the blood vessels may be performed to stop the bleeding. If needed, surgical removal of the uterus or hysterectomy may be recommended, although this procedure is rarely performed.
After the bleeding stops, 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 checking a complete blood count. Such monitoring is not only done after the bleeding has stopped, but from the start periodically as long as the doctor is trying to stop the bleeding.
Complications of Postpartum Bleeding
Postpartum bleeding can cause some serious complications, namely:
- Hypovolemic shock
- Disseminated intravascular coagulation (DIC), which is widespread blood clots throughout the body
- Acute kidney failure
- Acute respiratory distress syndrome
- Failure to function various organs of the body, can be due to shock or DIC
Prevention 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 regularly check the content with a gynecologist. That way, the doctor can find out whether you are at risk for abnormal bleeding, so that the doctor can provide and prepare for treatment before, during, and after the delivery process.