In this section
Heavy vaginal bleeding more than 24 hours after birth, and commonly after discharge from hospital, is a substantial contributor to maternal morbidity and mortality.
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tract occurring more than 24 hours to 6 weeks after delivery.
1. Assess patient
The diagnosis and management of a secondary post-partum haemorrhage primarily relies on clinical assessment. Ultrasound, looking for retained products of conception, should play a minor secondary role, as it has a high false positive rate (low specificity) which may lead to unnecessarily aggressive intervention with a significant risk of serious consequences. Ultrasound does not easily differentiate between retained products and blood clot.
2. Treat the Cause
General principles of treatment
Retained products of conception
Bleeding in the first few days after delivery is probably due to retained products of conception. Gentle digital evacuation of the uterus under general anaesthesia should be considered. Antibiotic therapy is indicated prior to the procedure.
Bleeding occurring later in the puerperium is most usually due to infection of the uterus, for which antibiotics should be prescribed. If bleeding continues despite antibiotics, exploration of the uterus is indicated.