Postpartum Hemorrhage

What is postpartum hemorrhage?

Postpartum hemorrhage (PPH) is severe bleeding after giving birth. It’s a serious and dangerous complication that requires immediate treatment. PPH usually occurs within 24 hours of childbirth, but it can happen up to 12 weeks after delivery (postpartum). With PPH, you can lose large amounts of blood very quickly. It causes a sharp drop in blood pressure, which can restrict blood flow to your heart, brain and other organs. When your organs don’t get enough blood flow due to active bleeding, this is called hypovolemic shock which can be deadly. The labor and delivery team needs to find and stop the bleeding as quickly as possible.

Bleeding excessively after giving birth can be scary and traumatic. You probably didn’t expect your birth experience to go this way. It’s important to share any concerns about excessive bleeding after delivery with your pregnancy care provider so they can identify signs of PPH as soon as they occur. With early detection and prompt treatment, most people make a full recovery. Most PPHs occur immediately after delivery.

Postpartum hemorrhage occurs in about 1 to 5 of every 100 deliveries (1% to 5%), and most cases aren’t life-threatening with prompt treatment.

How much blood loss is considered postpartum hemorrhage?

Postpartum hemorrhage is when:

• The total blood loss is greater than 33 fluid ounces (1 liter) after delivery, regardless of whether it’s a vaginal delivery or a C-section delivery

AND/OR:

• When you display signs of too much blood loss like a significant change in heart rate and/or blood pressure

What are the types of postpartum hemorrhage?

There are two types of PPH: primary and secondary (late).

• Primary postpartum hemorrhage occurs within the first 24 hours after delivery.
• Secondary or late postpartum hemorrhage occurs 24 hours to 12 weeks after delivery.

How do I know if I’m hemorrhaging postpartum?

The most common symptom of postpartum hemorrhage is persistent, excessive vaginal bleeding after delivery. This can include passing several large blood clots (anything larger than a golf ball may be a sign of a problem).

Other signs of PPH are:

• Symptoms of a drop in blood pressure like dizziness, blurred vision or feeling faint
• Increased heart rate (tachycardia)
• Decreased red blood cell count (hematocrit levels)
• Pale or clammy skin
• Pain and swelling in your vaginal or perineal area (when blood collects outside of a blood vessel)

Tell your healthcare providers about any concerning symptoms or changes you notice 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.

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 the fetus during pregnancy. After your baby is born, your uterus continues to contract to deliver the placenta. 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. 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 your reproductive organs are damaged during delivery.

Most cases of PPH happen within 30 to 60 minutes of giving birth.

What are the four Ts of postpartum hemorrhage?

The causes of postpartum hemorrhage are often called the four Ts (tone, trauma, tissue and thrombin). The following conditions or factors summarize the most common causes of PPH:

• Uterine a’T’ony. 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 ‘T’rauma. Damage to your vagina, cervix, uterus or perineum causes bleeding. Sometimes, pooled blood can collect in a concealed area and the injured tissue can continue to bleed hours or days after delivery.
• Retained placental ‘T’issue. This is when the entire placenta doesn’t separate from your uterine wall. Sometimes, this is because of an abnormality in the placenta, but this can also occur with a normal placenta.
• Blood clotting condition (‘T’hrombin): If you have a coagulation disorder or pregnancy condition that impacts your ability to clot, there’s a higher chance that even a tiny bleed can become significant.

Who is at a higher risk for postpartum hemorrhage?

Postpartum hemorrhage can affect anyone after childbirth. There are many risk factors for PPH, but approximately 40% of hemorrhages occur without any risk factors. Healthcare providers may not be able to prevent PPH from happening, but identifying risk factors before delivery can help reduce the chances of severe blood loss.

Conditions that affect the placenta

Your risk of postpartum hemorrhage is higher if you have a condition that affects your placenta. These conditions may include:

• Placenta previa
• Placental abruption
• Placenta accreta

Conditions that affect labor or delivery

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

• Receiving general anesthesia (getting put to sleep)
• You were given medications to stop labor contractions (tocolytics)
• Prolonged labor or prolonged exposure to oxytocin (Pitocin®) to help your uterus contract
• Quick labor (giving birth less than three hours after going into labor)
• Use of forceps or a vacuum during a vaginal birth
• Significant vaginal tearing (lacerations)
• Cesarean delivery

Other health conditions

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

• Blood clotting disorders or bleeding disorders like von Willebrand disease
• Receiving a medication called magnesium sulfate, which is used to treat severe preeclampsia
• Pregnancy conditions that affect clotting factors and/or platelets such as HELLP syndrome or gestational thrombocytopenia
• Chorioamnionitis (infection in the amniotic sac)
• Obesity
• Advanced maternal age

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

• A history of five or more previous deliveries
• Having twins, triplets or more
• Delivering a large baby (macrosomia)
• Having too much amniotic fluid (polyhydramnios)

What are the 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. Shock is when your organs don’t receive enough blood. It can lead to organ failure or death.

What are signs of hemorrhage after a C-section?

Most of the symptoms of PPH are the same in a C-section as a vaginal delivery. Some of those signs include:

• Increase in heart rate
• Cold or clammy hands and feet
• Shortness of breath or difficulty breathing
• Bloating, bruising or pain in your abdomen in places other than the incision cite
• Heavy vaginal bleeding and passing large blood clots

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 may also be important to assess the risk and impact of a PPH.

Postpartum hemorrhage is diagnosed based on the amount of blood you’ve lost. Counting or weighing the blood-soaked pads or sponges from delivery is one common way to approximate blood loss.

Other tools that may be used to evaluate you if there’s concern for a PPH are:

• Continual monitoring of your pulse rate and blood pressure to detect problems
• Blood tests to measure red blood cells (hematocrit) and blood clotting factors
• Pelvic exam to check your vagina, cervix and uterus
• Ultrasound to get a detailed image of your uterus

How is postpartum hemorrhage treated?

Healthcare providers treat PPH as an emergency in most cases. Stopping the source of the bleeding as fast as possible is the main goal of treatment.

Your provider may use any of the following treatments depending on what’s causing your bleeding and how severe the bleeding is:

• Uterine massage to help the muscles of your uterus contract
• Medication to stimulate contractions
• Removing retained placental tissue from your uterus which can happen manually or with a procedure
• Repairing vaginal, cervical and uterine tears with stitches
• Using a catheter or balloon to help put pressure on your uterine walls to compress the bleeding
• Procedures to stop the blood supply to the uterus
• Giving you a blood transfusion
• Replacing lost fluids with intravenous (IV) fluids
• Giving you supplemental oxygen through a mask
• Prescribing iron supplements

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

How long does it take to recover from PPH?

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.

How can I prevent hemorrhaging during childbirth?

The best way for healthcare providers to prevent postpartum hemorrhage is to identify people at a higher risk for postpartum hemorrhage before delivery. You can help your provider by sharing your full medical history and letting them know if you have symptoms of postpartum hemorrhage after delivery.

Is it safe to have another baby after postpartum hemorrhage?

Yes, it’s usually safe to have another baby. Talk to your healthcare provider about your risk of hemorrhage with future deliveries. While your risk is slightly higher than normal, it’s still low. Your provider can go over your risk factors and determine if any precautions should be taken in future deliveries.

How do I take care of myself after a postpartum hemorrhage?

It can be difficult to care for a newborn while also caring for yourself, but getting rest and taking care of yourself can help you feel better. Your self-care is important. Some tips for prioritizing your wellness include:

• Resting. Your body needs time to heal. Don’t be afraid to ask for help so you can get the rest you need.
• Eating nutritious foods. Iron-rich foods like red meat, leafy greens and fortified breakfast cereals can help with red blood cell production. Reaching for nutritious foods helps support your recovery.
• Drinking water. Be sure to drink plenty of water after birth to prevent dehydration.
• Following your provider’s instructions. Your provider may prescribe medications or lifestyle modifications to help you heal. Follow their instructions.
• Monitor your bleeding. Wear a sanitary pad and watch how long it takes to fill it. Your bleeding should gradually decrease over several weeks. If it doesn’t, contact your healthcare provider.

Experiencing excessive bleeding can be traumatic. It’s OK if it takes time to heal emotionally from your birth experience. You may need support from your family, friends, healthcare providers or others. Share how you’re feeling and ask for help when you need it.

When should I see my healthcare provider?

Most cases of postpartum hemorrhage occur at delivery or right after when you’re still at the hospital or birthing center. If you bleed heavily or experience any symptoms of postpartum hemorrhage once you’re home, contact your healthcare provider immediately. If your provider’s office is closed or you can’t get in contact with someone, you should go to the nearest emergency room.