Uterine Atony

Uterine atony is when your uterus doesn’t contract (or tighten) shortly after childbirth. It can cause life-threatening bleeding. “Atony” means something has lost its muscle tone. With uterine atony, your uterus is soft and squishy instead of firm.

After birth, contractions help squeeze your blood vessels closed. When the muscles aren’t squeezing enough, the blood flows freely. This can lead to severe bleeding after birth (postpartum hemorrhage). This is a medical emergency. It can happen after vaginal births or C-section deliveries.

Uterine atony can also occur during a miscarriage or other uterine surgeries. Most women make a full recovery when it’s treated promptly.

Symptoms of uterine atony

The biggest sign is heavy or excessive bleeding. Your healthcare provider can usually detect this soon after delivery.

Your healthcare provider will do a quick exam to check your uterus. Your uterus may feel soft, which providers often call a “boggy uterus.” Your uterus should feel firm.

Other than severe bleeding and a boggy uterus, other signs and symptoms are:

• Low blood pressure
• Fast heart rate
• Feeling dizzy or faint
• Pale appearance
• Losing consciousness
• Not being able to pee
• Pain, especially in your back

Uterine atony causes

Uterine atony happens when your uterine muscles don’t contract strongly enough after childbirth. Certain hormones should help your uterus tighten up after delivery. This tightening helps control bleeding. Without contractions, bleeding can become severe.

Risk factors for uterine atony

Your risk may be greater if:

• This is your first baby or you’ve had more than five babies.
• You’re having multiple babies (like twins or triplets).
• Your baby is larger than average.
• You’re older than 35.
• You have too much amniotic fluid.
• You have obesity.
• You have uterine fibroids.
• You’ve had heavy bleeding in a previous delivery.

If the following factors happen during labor, your uterus may not contract after delivery:

• You’ve had a very long, fast or difficult labor.
• Your labor is induced.
• You have an infection in your uterus, like chorioamnionitis.
• You’ve had general anesthesia.
• You have an enlarged uterus.

Having more than two risk factors puts you at high risk for uterine atony. Knowing this ahead of time helps your healthcare team prepare for quick treatment.

How to reduce your risk

Uterine atony can’t usually be prevented. If you’re at risk, your healthcare provider may take steps ahead of time to prepare. This could include having extra help in the delivery room or delivering your baby at a hospital with the resources you need. You can take steps to have a healthy pregnancy by attending all of your prenatal appointments and maintaining a healthy weight.

Complications of uterine atony

Uterine atony can lead to severe blood loss. Without prompt treatment, you’re at risk for:

• Postpartum hemorrhage
• Needing a blood transfusion
• Needing a hysterectomy (rare)
• Shock or organ damage (in severe cases)

How doctors diagnose uterine atony

Healthcare providers know how to spot uterine atony early and treat it fast. They can usually diagnose it by feeling the size and softness of your uterus after delivery. This typically involves your provider placing one hand on your abdomen while also performing a vaginal exam. If you have uterine atony, your uterus is large, soft and weak. Your uterus should begin contracting (tightening or hardening) and shrinking after delivery.

Some providers may weigh or count the sponges or pads used to absorb blood to estimate how much blood you’ve lost.

Uterine atony is the leading cause of postpartum hemorrhage, so your provider will also examine you for:

• Tears in your cervix, vagina or uterus
• Retained placental tissue

Your provider will continue to watch for changes in your blood pressure and heart rate. They may order blood tests to look at your red blood cell count and check how fast your blood clots.

How is it treated?

Uterine atony is an emergency and requires quick action from your healthcare team. The goal of treatment is to stop the bleeding as soon as possible and replace any lost blood or fluids. Even after the bleeding is under control, you may need a blood transfusion or IV fluids to replace what was lost.

Your pregnancy care provider typically begins treatment by massaging your uterus to promote stronger contractions. Depending on the severity, this may be enough to stop the bleeding.

Your provider may give you medication to help your uterus contract. This could include:

• Oxytocin (Pitocin®)
• Methylergonovine (Methergine®)
• Prostaglandins, like 15-methyl-PGF2 (Hemabate®), misoprostol (Cytotec®) or dinoprostone
• Ergot alkaloids, like ergometrine

If this doesn’t work to stop the bleeding, your provider may try applying pressure to your uterus (tamponade techniques). This involves packing your uterus with gauze or inflating a Bakri or Cook balloon inside your uterus. With these methods, your provider places direct pressure on your uterine wall to stop the bleeding.

Surgery may be necessary if all other methods don’t stop the bleeding. The surgeries to treat uterine atony are:

• Uterine curettage: Your provider scrapes retained blood or placental tissue from your uterus (if that’s the cause of bleeding). This is sometimes called a D&C.
• Uterine artery ligation: Your provider ties off blood vessels in your uterus.
• Uterine artery embolization: Your provider uses small sand-like particles to block blood flow to your uterus.
• Hysterectomy: Removing your uterus is the final measure if other treatments haven’t worked.

What can I expect if I have uterine atony?

Uterine atony is usually an emergency. You’ll need treatment to stop the bleeding and prevent serious complications. Your healthcare team will monitor your vital signs closely while this happens. It can be scary to experience, but most women recover fully with prompt care. With quick treatment, most make a full recovery.

This condition doesn’t prevent you from having a future pregnancy. If you do get pregnant in the future, your healthcare team will watch you closely to keep you safe.

Can it happen twice?

Yes. You’re at higher risk of having it again if you’ve already had uterine atony.