Haemorrhaging in Labour
Haemorrhaging (bleeding) that occurs during and after childbirth can be a major hazard if severe, and will need immediate medical attention.
Haemorrhage can be divided into three areas: antepartum (before labour), intrapartum (during labour) and postpartum (following labour).
Antepartum haemorrhage can be caused by placental problems during pregnancy like premature separation of the placenta from the uterine wall, or may arise in cases of placenta praevia where the placenta lies over the cervix. In approximately 5% of cases, antepartum haemorrhage is due to local causes, ie the vagina or cervix. However, in almost 40% of cases, no cause is identified. An isolated episode of antepartum bleeding where no cause is found is not associated with any increased risk for the pregnancy. Recurrent bleeding may indicate a high-risk pregnancy, with the most common complication being early delivery.
Intrapartum haemorrhage, which is bleeding that occurs during labour, may be caused by premature separation of the placenta from the uterine wall, or may arise in cases of placenta praevia where the placenta lies over the cervix. It is unusual these days, with ultrasound examinations during pregnancy becoming more common, for placenta praevia to cause bleeding during labour, as most cases are diagnosed before labour and delivered by caesarean section. Heavy bleeding during labour is more likely to be due to premature separation of the placenta or abruption, which may also cause pain in the abdomen or fetal distress. Mild bleeding may come from the cervix, or may just be an unusually heavy form of ‘show’.
If heavy bleeding does occur during childbirth, then a blood transfusion may be necessary. Saline and other fluids will also be given intravenously, and blood pressure and pulse monitored. In addition, the baby will often need to be delivered by caesarean section. If the bleeding is only mild, the labour will be closely monitored, particularly the amount of bleeding, the baby’s heart rate and how the labour progresses. Your obstetrician will discuss the option of caesarean section with you if there are any risks to the baby.
Postpartum haemorrhage is bleeding that occurs from the genital tract after the baby is born and is caused by various factors. These include excessive bleeding from where the placenta was attached to the uterine wall. This can be either due to the failure of the uterus to contract efficiently after the baby is delivered, or because some of the placenta has been left inside the uterus after birth. It may also result from tearing along the birth canal, which is more likely after an assisted delivery. Postpartum haemorrhage is most commonly seen after an extended labour, a caesarean section or following a multiple pregnancy when in labour.
If significant bleeding occurs after your delivery, an IV line will be inserted; it is not unusual to have two IV lines in this scenario. Additional medication is given to contract the uterus, into the IV line or administered by rectal placement or intramuscular injection. Occasionally, you may need more extensive treatment such as blood transfusion or transfer to the operating theatre for a more detailed examination or, in rare cases, an operation can be required to stop the bleeding.
In most women, a drug consisting of the uterine stimulants ergometrine and synthetic oxytocin (known as syntocinon) is routinely used to prevent postpartum haemorrhage. (You may be more familiar with the trade name of this combination drug, which is Syntometrine). These medications are also used either alone or in combination to treat postpartum haemorrhage.
Some bleeding at the time of delivery is normal. In fact, a pregnant woman can lose up to 15% of her blood volume at the time of delivery without her blood count dropping or developing anaemia. This is because the enlarged womb contains quite a large amount of blood that is squeezed back into the mother’s blood stream after delivery. This is designed to make up for the amount lost at delivery of the baby and when the placenta separates from the uterine wall. Contraction of the womb after the placenta is delivered also stops the womb from bleeding heavily.
If postpartum haemorrhage does occur, your midwife and/or obstetrician will assess you to determine the amount of blood lost, and what the cause is. Initially, this may just involve feeling your tummy to check the uterus has contracted, as well as giving you some fluids intravenously. Your obstetrician may also rub your uterus through your stomach to encourage it to contract.
You will also be given a drug to help the uterus contract, usually ergometrine and/or syntocinon, but sometimes a prostaglandin injection as well. If the bleeding is heavy, however, the lost blood may need to be replaced by a blood transfusion, and the woman may have to be treated for shock. Any tears causing bleeding will be stitched and, if it is suspected that any of the placenta has been left behind, you will be examined under an anaesthetic and any placental tissue removed.