Postpartum Hemorrhage

What is postpartum hemorrhage?

Postpartum hemorrhage (PPH) is severe bleeding after giving birth. It's a serious and dangerous condition. PPH usually occurs within 24 hours of childbirth, but it can happen up to 12 weeks postpartum. When the bleeding is caught early and treated quickly, it leads to more successful outcomes.

Postpartum hemorrhage is when the total blood loss is greater than 32 fluid ounces after delivery, regardless of whether it’s a vaginal delivery or a Cesarean section, or C-section, or when bleeding is severe enough to cause symptoms of too much blood loss or a significant change in heart rate or blood pressure.

What are the types of postpartum hemorrhage?

There are two types of PPH. Primary postpartum hemorrhage occurs within the first 24 hours after delivery. Secondary or late postpartum hemorrhage occurs 24 hours to 12 weeks postpartum.

Why does postpartum hemorrhage occur?

There are a few reasons why postpartum hemorrhage occurs.

Your placenta attaches to the wall of your uterus and provides food and oxygen to your baby during pregnancy. After your baby is delivered, your uterus continues to contract to deliver the placenta. This is called the third stage of labor. Contractions also help to compress the blood vessels where the placenta was attached to your uterine wall. Sometimes, these contractions aren’t strong enough to stop the bleeding (called uterine atony). This is the cause of up to 80% of postpartum hemorrhages.

Postpartum hemorrhage can also happen if parts of the placenta stay attached to your uterine wall or if parts of your reproductive organs are damaged during delivery. You’re at an increased risk for PPH if you have a blood clotting (coagulation) disorder or certain health conditions.

Who does it affect?

Postpartum hemorrhage can affect anyone after childbirth. There are many risk factors for PPH, but approximately 40% of hemorrhages occur in women without any risk factors. Most postpartum hemorrhage occurs right after the placenta is delivered. PPH may be more likely after a C-section.

How common is postpartum hemorrhage?

Postpartum hemorrhage occurs in about 1% to 10% of pregnancies.

How serious is postpartum hemorrhage?

Postpartum hemorrhage is a serious and potentially fatal condition. With PPH, you can lose large amounts of blood very quickly. It causes a sharp decline in blood pressure, which can restrict blood flow to your brain and other organs. This is called shock, and it can lead to death. Postpartum hemorrhage is a medical emergency and needs to be treated right away.

What are the four most common causes of postpartum hemorrhage?

The causes of postpartum hemorrhage are called the four Ts (tone, trauma, tissue and thrombin).

The most common causes of PPH are:

• Uterine atony: Uterine atony (or uterine tone) refers to a soft and weak uterus after delivery. This is when your uterine muscles don’t contract enough to clamp the placental blood vessels shut. This leads to a steady loss of blood after delivery.
• Uterine trauma: Damage to your vagina, cervix, uterus or perineum (area between your genitals and anus) causes bleeding. Using instruments like forceps or vacuum extraction during delivery can increase your risk of uterine trauma. Sometimes, a hematoma (collection of blood) can form in a concealed area and cause bleeding hours or days after delivery.
• Retained placental tissue: This is when the entire placenta doesn't separate from your uterine wall. It’s usually caused by conditions of the placenta that affect your uterus’s ability to contract after delivery.
• Blood clotting condition (thrombin): If you have a coagulation disorder or pregnancy condition like eclampsia, it can interfere with your body’s clotting ability. This can make even a tiny bleed uncontrollable.

How do I know if I'm hemorrhaging postpartum?

The most common symptom of postpartum hemorrhage is persistent, excessive bleeding after delivery.

Other signs of PPH are:

• Symptoms of a drop in blood pressure like dizziness, blurred vision or feeling faint.
• Increased heart rate.
• Decreased red blood cell count.
• Pale or clammy skin.
• Nausea or vomiting.
• Worsening abdominal or pelvic pain.

Be honest with your healthcare providers about how you’re feeling after delivery. In some cases, PPH doesn’t cause symptoms until after you’ve left the hospital. Contact your healthcare provider immediately if you feel any of the symptoms above in the days or weeks after giving birth.

How is postpartum hemorrhage diagnosed?

Healthcare providers diagnose postpartum hemorrhage through visual and physical examinations, lab tests and a thorough review of your health history.

They may detect postpartum hemorrhage based on the amount of blood you’ve lost. Measuring the volume of collected blood and weighing the blood-soaked pads or sponges from delivery is one common way to approximate blood loss.

Other methods to diagnose PPH are:

• Continual monitoring of your pulse rate and blood pressure to detect problems.
• Blood tests to measure red blood cells (hematocrit) and clotting factors.
• Ultrasound to get a detailed image of your uterus and other organs.

How do doctors treat postpartum hemorrhage?

Healthcare providers treat PPH as an emergency in most cases. Stopping the source of the bleeding as fast as possible and replacing blood volume are the goals of treating postpartum hemorrhage.

Some of the treatments used are:

• Uterine massage to help the muscles of your uterus contract.
• Medication to stimulate contractions.
• Removing retained placental tissue from your uterus.
• Repairing vaginal, cervical and uterine tears or lacerations.
• Packing your uterus with sterile gauze or tying off the blood vessels.
• Using a catheter or balloon to help put pressure on your uterine walls.
• Uterine artery embolization.
• Blood transfusion.

In rare cases, or when other methods fail, your healthcare provider may perform a laparotomy or a hysterectomy. A laparotomy is when your surgeon makes an incision in your abdomen to locate the source of bleeding.

What medications treat postpartum hemorrhage?

You may be given medications to help induce contractions if uterine atony is the cause of the bleeding. The most common drugs used are oxytocin, methylergonovine or prostaglandins like carboprost or misoprostol.

What are the potential complications of postpartum hemorrhage?

Excessive blood loss can cause several complications like increased heart rate, rapid breathing and decreased blood flow. These symptoms can restrict blood flow to your liver, brain, heart or kidneys and lead to shock. In some cases, Sheehan’s syndrome (a condition of the pituitary gland) is seen after postpartum hemorrhage.

Who is at a higher risk for postpartum hemorrhage?

Those with placental problems like placenta accreta, placenta previa, placental abruption and retained placenta are at the highest risk of PPH.

An overdistended uterus also increases the risk for PPH. This is when your uterus is overstretched from:

• Multiple pregnancies.
• Having twins, triplets or more.
• Birthing a large baby (9 pounds or more).
• Too much amniotic fluid.

Certain factors during labor and delivery can increase your risk for hemorrhage:

• C-section.
• You were given oxytocin (Pitocin®) to include labor.
• You were given general anesthesia.
• You were given tocolytics to stop labor.
• Prolonged labor.
• Infection during labor.
• Tearing (perineal lacerations) during vaginal delivery.
• You’ve had PPH in prior deliveries.

Other health conditions that can increase your risk for postpartum hemorrhage are:

• High blood pressure or preeclampsia.
• Infection.
• Blood clotting disorders or other blood-related conditions.
• Intrahepatic cholestasis of pregnancy (ICP).
• Anemia.
• Obesity.
• Advanced maternal age.
• A history of five or more previous deliveries.

How can I prevent hemorrhaging during childbirth?

The best way for healthcare providers to prevent postpartum hemorrhage is to identify those at high risk for postpartum hemorrhage before delivery. This is dependent on you sharing your complete medical history and symptoms with your healthcare provider. Routinely giving medications like oxytocin at the time of delivery to help your uterus contract is also important. Ensuring adequate iron intake and red blood cell levels during pregnancy can minimize the impact of postpartum hemorrhage should it occur.

How does postpartum hemorrhage lead to death?

Postpartum hemorrhage can lead to death without prompt treatment. Excessive blood loss can lead to shock. Shock is when your organs don’t receive enough blood.

How do you recover from postpartum hemorrhage?

Recovery is different for everyone. Recovering from a postpartum hemorrhage depends on the severity of blood loss and how your healthcare provider treated it. Be sure to take care of yourself in the days following delivery — eating healthy, drinking lots of water and resting as much as possible. Your healthcare provider may recommend an iron supplement to help with anemia.

A note from Cleveland Clinic

Postpartum hemorrhage is a serious condition that requires medical attention as soon as possible. Contact your healthcare provider immediately if you’re experiencing severe bleeding after childbirth. Other signs of postpartum hemorrhage are dizziness, feeling faint and blurred vision. Early detection and prompt treatment can help prevent complications. It’s important to be open with your healthcare provider about your medical history so they can determine if you’re at higher risk for postpartum hemorrhage.