If the haematoma appears to be getting bigger, with evidence from serial - usually
daily - ultrasound scans and/or falling blood count (haemoglobin), then there is
no choice but to perform an operation to stop this. A laparotomy (where the abdomen
is opened) will be performed and the clot evacuated. The bleeding points are sought
and secured. It is a major operation which will prolong the new mother's hospital
stay for probably four to seven days.
Postpartum haemorrhage (PPH)
How common is delayed postpartum haemorrhage (PPH)?
Significantly heavy bleeding occurring more than 24 hours after delivery affects
around 1 per cent of all new mothers. The technical term is secondary PPH (postpartum
haemorrhage). It may occur any time in the first six weeks following delivery, but
is most common between the first and second week. Secondary PPH after the first four
weeks is quite uncommon.
What causes secondary postpartum haemorrhage?
The cause is not always identifiable.
The two known causes are:
Retained products of conception where some bits of placenta or membranes are not
Infection of the lining of the womb.
How common is the problem of retained products after delivery?
It is less common than one may be tempted to imagine. In fact, a lot of cases purported
to be retained products following ultrasound scan turn out not to be this. Following
this apparent diagnosis, evacuation of the uterine contents is done and, as it turns
out in many cases, only clots are retrieved. Because of this, manyobstetricians
regard ultrasound in a person with symptoms of secondary PPH to be an ill-advised
venture, since it is likely to lead to a uterine evacuation procedure, mostly under
a general anaesthetic, which in many cases turns out to be unnecessary.
How will one recognize secondary postpartum haemorrhage (PPH) caused by infection?
There are usually clinical features that may point towards this possibility. These
may include pelvic pain, fever and general malaise. Then again, these may be completely
Tests are usually done, including a blood count and vaginal swabs to look for the
culprit bacteria. These may be inconclusive. In fact, the value of taking vaginal
swabs in a woman who is bleeding from the uterus is doubtful. Many experts argue
that if one really wants to identify the infection, swabs have to be taken from high
up in the womb itself. This is usually an impractical option, unless the woman is
being taken to theatre for evacuation of the uterus.
So, how does one go about managing secondary postpartum haemorrhage where there is
no readily identifiable cause?
A clinical judgement has to be made according to each individual's case. The management
may include some or all of these:
Oxytocic drugs to promote uterine contraction,
Uterine exploration for retained products and
Transfusion is mentioned here but in fact it is rarely required in secondary PPH.