CAUSES: The bleeding usually occurs between 8th and 14th day of delivery. The causes of late postpartum hemorrhage are:

1) Retained bits of cotyledon or membranes (most common),

2) Infection and separation of slough over a deep cervicovaginal laceration,

3) Endometritis and sub involution of the placental site-due to delayed healing process

4) Secondary hemorrhage from cesarean section wound usually occur between 10–14 days. It is probably due to-

1. a) Separation of slough exposing a bleeding vessel
2. b) From granulation tissue

5) Withdrawal bleeding following estrogen therapy for suppression of lactation

6) Other rare causes are: Chorionepithelioma - occurs usually beyond 4 weeks of delivery, Carcinoma cervix, Placental polyp, Infected fibroid or fibroid polyp and puerperal inversion of uterus.

DIAGNOSIS: The bleeding is bright red and of varying amount. Rarely it may be brisk. Varying

degree of anemia and evidences of sepsis are present. Internal examination reveals evidences of sepsis,

subinvolution of the uterus and often a patulous cervical os. Ultrasonography is useful in detecting the

bits of placenta inside the uterine cavity.

MANAGEMENT: -

Principles:

• To assess the amount of blood loss and to replace it (blood transfusion).
• To find out the cause and to take appropriate steps to rectify it.

SUPPORTIVE THERAPY:

1) Blood transfusion, if necessary.

2) Conservative: If the bleeding is slight and no apparent cause is detected, a careful watch for a period of 24 hours or so is done in the hospital.

3) Active treatment: As the most common cause is due to retained bits of cotyledon or membranes, it is preferable to explore the uterus urgently under general anesthesia. One should not ignore the small amount of bleeding; as unexpected alarming hemorrhage may follow sooner or later. The products are removed by ovum forceps. Gentle curettage is done by using flushing curette. The materials removed are to be sent for histological examination.

HOMOEOPATHIC MEDICINE FOR SECONDARY POSTPARTUM HEMORRHAGE: -

There are several homoeopathic medications like: Secale, Trilium,  Ipecacuanha,  Hamamelis, Cinchona, along with various others that can be used for the treatment of Haemorrhage. However, it is best to consult an expert for availing medicines that are ideal to treat one's individualistic health complications.