By The PPH Foundation
While uterine atony remains the leading cause of postpartum haemorrhage, trauma is the second major contributor and an often under recognized threat. In the context of PPH, trauma refers to physical injury to the birth canal during delivery. These injuries may involve tears to the cervix, vagina, or perineum, episiotomy extensions, uterine rupture, or damage following operative vaginal birth or caesarean section. Even when the uterus is well contracted, uncontrolled bleeding can occur if trauma is present.
Global clinical reviews indicate that trauma accounts for approximately 15 to 20 percent of postpartum haemorrhage cases. According to the World Health Organization, postpartum haemorrhage contributes to about 27 percent of maternal deaths worldwide, underscoring the need to address every major cause, including birth related injuries.
Dr Kireki Omanwa, President of the Kenya Obstetrical and Gynaecological Society and End PPH Initiative Co Lead, explains that trauma related PPH can be deceptive. The uterus may feel firm on examination, yet bleeding continues. In such cases, the source is often a tear that requires immediate identification and repair. He emphasizes that careful inspection of the birth canal after every delivery is not optional but lifesaving.
Several risk factors increase the likelihood of traumatic PPH. These include prolonged or obstructed labour, instrumental deliveries using forceps or vacuum, delivery of a large baby, rapid labour, and previous uterine surgery. Inadequate skilled attendance at birth also raises the risk of missed or poorly managed tears. In severe cases, uterine rupture may occur, particularly in women with a previous caesarean scar or obstructed labour without timely intervention.
The signs of trauma related PPH include persistent bright red bleeding despite a firm uterus, visible lacerations, swelling or hematoma formation in the perineal area, severe pelvic pain, and signs of shock such as rapid pulse, low blood pressure, pallor, or restlessness. Early recognition requires vigilance and systematic examination immediately after delivery.
Prevention begins with quality intrapartum care. Skilled birth attendants trained in safe delivery techniques can reduce unnecessary trauma. Judicious use of episiotomy, careful use of instruments, timely decision making during obstructed labour, and adherence to clinical guidelines all play a role. Strengthening referral systems ensures that complicated labours are managed in facilities equipped for comprehensive emergency obstetric care.
Management of traumatic PPH depends on rapid assessment and intervention. This includes immediate visual inspection of the cervix, vagina, and perineum, surgical repair of tears under appropriate anaesthesia, evacuation of hematomas where necessary, fluid resuscitation, administration of tranexamic acid, and blood transfusion when indicated. In cases of uterine rupture, urgent surgical intervention is required to control bleeding and repair or remove the uterus to save the woman’s life.
Dr Kireki notes that trauma related haemorrhage is preventable with skilled care and prompt action. He stresses that every birth must be followed by a thorough examination, because missing a tear can have fatal consequences. Ending preventable maternal deaths requires attention to all Four Ts of PPH, with trauma demanding the same urgency as uterine atony.
Sources
World Health Organization, WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage
World Health Organization, Trends in Maternal Mortality
FIGO Guidelines on the Management of Postpartum Haemorrhage
Kenya Obstetrical and Gynaecological Society Clinical Guidance on PPH
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