Excessive bleeding after delivery accounts for 30 to 40 per cent of maternal deaths in Malaysia.
DURING pregnancy, a woman spends nine months praying that nothing will happen to her baby. Then the big day comes and she delivers her child. But that doesn't mean the danger is over ... for her.
All pregnant women experience postpartum bleeding in the days and weeks following birth. This is normal and it is a sign that your uterus is healing. However, some women may experience postpartum haemorrhage (PPH) following labour and delivery. This abnormal postpartum bleeding can be life-threatening and requires immediate medical attention.
PPH is the most important single cause of maternal death in the world. The World Health Organisation estimates that every year, more than 150,000 women die as a result of this excessive bleeding.
In Malaysia, it accounts for 30 to 40 per cent of maternal deaths. According to our 1996 Confidential Enquiries of Maternal Deaths (CEMD), 60 women died of PPH in 1995 and 44 in 1996.
Consultant obstetrician and gynaecologist Dr Yap Moy Juan explains that PPH is most commonly defined as losing 500ml of blood or more after a vaginal birth.
"If this significant loss of blood occurs within 24 hours of childbirth, it is considered to be early or primary PPH. After 24 hours, if PPH occurs, it is referred to as late or secondary. The majority of PPH occurs within 24 hours after labour," explains Dr Yap.
She says that in most of the cases, PPH is the result of the failure of the uterus to properly contract and retract after birth. This is known as uterine atony. "If the uterus does not contract strongly enough, the blood vessels bleed freely and haemorrhage occurs."
Other causes of PPH include:
* Failure to deliver the placenta
* Forced removal of the placenta
* Trauma to the genital tract (i.e. use of forceps, uterine rupture, lacerations)
* Clotting disorders
* Induced labour
Dr Yap says that the first sign of haemorrhage is excessive bleeding, usually immediately after the baby is born. If the blood loss is not treated, later signs and symptoms include a rapid pulse, low blood pressure, weakness, fainting, and shock. It may lead to death if not treated.
Some women are at greater risk of PPH than others. Conditions that may increase the risk of PPH occurring include PPH in a previous pregnancy, multiple pregnancies, carrying more than five pregnancies to term, delivering a large baby, placenta praevia, infection, obesity and medications to induce labour.
"The aim of treatment for PPH is to find and stop the cause of the bleeding as quickly as possible," says Dr Yap.
Treatment for PPH may include:
* medications to stimulate uterine contractions
* manual massage of the uterus to stimulate contractions
* removal of placental pieces that remain in the uterus
* tying off of bleeding blood vessels.
* laparotomy: surgery to open the abdomen to find the cause of bleeding
* hysterectomy: surgical removal of the uterus; in most cases, this is the last resort.
"Replacing lost blood and fluids is important in treating PPH. Intravenous (IV) fluids, blood and blood products may be given rapidly to prevent shock," says Dr Yap.
Although the rates of maternal mortality are quite low in the developed world, in countries where there is a lack of skilled healthcare providers along with poor transportation and emergency services, the numbers are much higher.
"Without the proper medical attention, a woman can die within two hours of haemorrhaging," she stresses. "If we increase knowledge and skills in the community and health facilities and prepare frontline providers to focus first and foremost on the biggest maternal killer, we will save mothers and their children."
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