SingaporeMotherhood | Pregnancy

April 2014

Need To Know: Postpartum Haemorrhage

Two-thirds of with postpartum haemorrhage (PPH) have no risk factors for this birth complication which happens in about five per cent of births worldwide. Dr Kelly Loi from the Health & Fertility Centre for Women tells us more about it.

What is postpartum haemorrhage? (PPH)

PPH is generally defined as the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby. It can be further classified as minor (500 – 1,000 ml) or major (more than 1,000 ml).


What causes PPH?

Causes of PPH include uterine atony, retained placenta, trauma and coagulopathy.
• Uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony. Tissue that is retained in the body from the placenta or foetus may lead to bleeding. Trauma from the delivery may tear tissue and vessels leading to significant postpartum bleeding. Coagulopathy occurs when there is a failure of clotting.

Is there any way to tell if a woman will have PPH? Who has a higher risk of getting it?

Women with pre-existing bleeding disorders such as haemophilia and women taking therapeutic anticoagulants are at increased risk of PPH. Some other risk factors include:

• Factors relating to the pregnancy:
– Antepartum haemorrhage or bleeding during the pregnancy
– Placenta praevia where the placenta sits low in the uterus covering the birth canal
– Multiple pregnancy with twins/ triplets
– Pre-eclampsia or pregnancy-induced hypertension
– Maternal obesity


Is there a higher risk with normal (vaginal) or Caesarean delivery?

There is usually a higher risk with Caesarean delivery. An emergency Caesarean has a nine-fold increased risk while an elective Caesarean has a four-fold increased risk especially if it is a repeat procedure for over the third time. However, a vaginal delivery also has some increased risk if the labour was long (over 12 hours), if the baby was big (more than 4 kg), and if forceps or vacuum was used.

If I had PPH during my first delivery, what are the chances that it will happen when I give birth again?

With a previous PPH there is a three-fold increase in risk of it happening again.
To prepare, let your doctor know about your previous history of PPH, ensure a good Hemoglobin level and take iron supplements if necessary. Inform your doctor so that he/she can actively take precautions, for example, administer medicine to help with uterine contractions and ensure there is blood available for transfusion if required.

What is the worst-case scenario for PPH?

In the most severe cases, haemorrhagic shock may lead to a heart attack and stroke as well as multi-organ failure. If all medical treatments fail, hysterectomy or removal of the womb is the definitive treatment in women with severe haemorrhage.

How is PPH treated?

Effective treatment of PPH requires early recognition, diagnosis, and prompt fluid resuscitation to minimise the potentially serious outcomes associated with postpartum haemorrhage.

To stop the bleeding, various medicines are available to induce the uterus to contract. The cause of the bleeding also has to be addressed, for example, any retained placental tissue should be removed and any trauma of the genital tract has to be repaired. Sometimes, surgical intervention is required. Various surgical techniques may be applied to stop the bleeding. However, hysterectomy may still be required especially in cases of placenta accreta where the placental tissue has invaded the wall of the uterus, or uterine rupture.

With all the advances in medicine now, why do women still suffer from PPH?

Many factors contribute to the occurrence of PPH. Despite all the medical advances, the course of labour and delivery has inherent risks which may manifest at any stage. PPH is one such risk.

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Need To Know: Postpartum Haemorrhage