Postpartum haemorrhage associated with caesarean section and caesarean hysterectomy

Excessive haemorrhage associated with caesarean section, commonly defined as blood loss in excess of 1000 ml, is frequently underestimated, but is documented as occurring in more than 5-10% of caesarean sections. Common causes are uterine atony, abnormal placentation, uterine trauma and sepsis. It is a major cause of maternal morbidity globally and of maternal mortality in low- and middle-income countries; however, many reports do not disaggregate it from postpartum haemorrhage in general. In this chapter, we outline preventive measures, including uterotonic agents, and provide treatment algorithms for managing excessive haemorrhage during and after caesarean section. Several management options, including uterotonic therapy, uterine compression sutures, balloon tamponade, blood-vessel ligation and uterine artery embolisation are described; each has a role for treating the different causes of caesarean section bleeding in different contexts. Caesarean hysterectomy is indicated when medical and conservative surgical measures are unsuccessful, and as first-line surgery for extensive uterine rupture and bleeding from morbidly adherent placentae. It has an incidence ranging from 1-4 per 1000 caesarean sections, significantly greater than that for vaginal delivery. Although it is a life-saving procedure, it is associated with significant morbidity, including massive blood transfusion and intensive care (10-48%), urological injury (8%) and the need for relook laparotomy (8-18%).