Secondary postpartum haemorrhage (puerperal haemorrhage)

This is vaginal bleeding between 48 hours and 6 weeks after delivery, usually between 6 and 14 days, and typically on the 10th day. It is usually due to infection, particularly in association with: (1) Retained pieces of placenta. (2) Obstructed labour, causing necrosis of the cervix and vaginal wall. (3) Caesarean section and breakdown of the the uterine wound (6.8).

PUERPERAL HAEMORRHAGE If bleeding is mild, observation may be all the patient needs. If she continues to bleed, or has signs of infection, give her antibiotics, such as chloramphenicol and metronidazole (2.9).

If bleeding is severe, she will need antibiotics, resuscitation, and exploration of her uterus for retained pieces of placenta. Be sure she is well resuscitated before you start exploring her!

EXPLORING AND EVACUATING A SEPTIC UTERUS is difficult. Sterilize 2 ring forceps (or swab holders), a Sims' speculum, and a big, blunt curette. Add them to the vaginal examination tray.

Scrub up, put on gloves and put her into the lithotomy position. Cover her with a lithotomy towel (a towel cut to expose her vulva). Give her ergometrine 0.5 mg, and pethidine 50 mg, and diazepam 10 mg intravenously. Inject the pethidine slowly. Or give her a general anaesthetic.

Clean her vulva with an antiseptic solution. If her cervix is wide open, insert two fingers into her uterus, and try to remove any pieces of placenta that you can feel. They are not easy to find, because her uterine cavity is large and its walls irregular. If you cannot remove pieces of placenta with your fingers, use ring forceps and a large curette, like this:

Put the Sims' speculum into her vagina. Ask a helper to hold it, so that you can see her cervix. Hold the front of her cervix with one ring forceps. Put the other ring forceps into her uterus. Push it in very gently, until it is at her fundus. Feel the size of her uterine cavity. Open the handles, turn the forceps and close them again. Pull out any placenta you have grasped. Do this several times in different parts of her uterus, until nothing more comes out.

Curette her uterus. Scrape it down the anterior wall, then the two side walls, and then the posterior wall. Lastly, scrape it across the fundus. Don't scrape too hard, or you may harm its lining. It will still feel irregular when you have finished scraping.

CAUTION ! Emptying a uterus in the puerperium is difficult, and can be dangerous. Its wall is soft, and you can easily perforate it. Never use a small curette, or any small instrument, because they will make a hole very easily. Work gently and carefully, and don't use a sound.

If her uterus is empty and she is still bleeding severely, pack it and her vagina (19.11a).

If packing her uterus fails to control bleeding (very unusual), proceed to laparotomy, and tie her uterine (see ''Stop Press') or internal iliac arteries (3.5). If this also fails (rare) do a hysterectomy (20.12).

If she has a secondary postpartum haemorrhage after Caesarean Section, see ''Stop Press'.