Signs and treatment of postpartum hemorrhage

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Is postpartum bleeding normal?

Yes. It's normal to have some vaginal bleeding and discharge immediately after giving birth. As the placenta detaches, it leaves open blood vessels that bleed into the uterus. After the placenta is delivered, the uterus usually contracts, closing off these blood vessels and slowing the bleeding.

This type of normal bleeding and discharge is called lochia. It's normally bright red at first but should get progressively lighter – in color and amount – over the first few weeks. Your body is prepared to deal with a certain amount of blood loss because your total blood volume increases by almost 50% during pregnancy.

Post-delivery, your provider will help your uterus contract by pressing firmly on your abdomen. You'll also get a synthetic form of the hormone oxytocin (Pitocin), which can help your uterus contract. Breastfeeding also helps because it prompts your body to release oxytocin naturally.

What is postpartum hemorrhage?

Unfortunately, some women bleed so much after giving birth that additional treatment is necessary. Excessive bleeding is called a postpartum hemorrhage (PPH).

Profuse bleeding that occurs within the first 24 hours is considered a primary postpartum hemorrhage (PPH, also called immediate PPH), and it happens in about 3 to 10% of births in the United States.

Less commonly, postpartum hemorrhage can happen in the days or weeks after delivery, which is called late (or delayed or secondary) PPH. Between 0.2 and 2.5% of postpartum women develop severe bleeding between 24 hours and 12 weeks after childbirth.

PPH can happen after a vaginal birth or after having a cesarean section.

What are the signs and symptoms of postpartum hemorrhage?

Excessive bleeding is the most obvious sign of postpartum hemorrhage.

You may also develop signs of shock, such as:

• Blurry vision
• Chills
• Nausea or vomiting
• Lightheadedness, weakness, or dizziness
• Rapid heartbeat or palpitations
• Rapid or shallow breathing
• Pale and/or clammy skin
• Restlessness
• Confusion

Call 911 for emergency care if you develop signs of shock and you aren't still at the hospital.

Risk factors for postpartum hemorrhage

Risk factors for postpartum hemorrhage include:

• Obesity

• Previous PPH or late PPH
• Previous pregnancies
• Maternal age of 35 years or older
• Large uterine fibroids

However, many women who have a PPH don't have any risk factors.

What causes postpartum hemorrhage?

The most common cause of PPH is when the uterus doesn't contract effectively after delivery. (This needs to happen to close the blood vessels that were connected to the placenta.) When this doesn't happen, the uterus stays large and soft, and bleeding occurs. This is called uterine atony.

Uterine atony is more likely to happen if:

• You gave birth to a very large baby
• You had twins, triplets, or other multiples
• You had too much amniotic fluid (polyhydramnios), causing an overly distended uterus
• Your labor was either rapid or prolonged, causing muscle exhaustion

Other causes of PPH include:

• Tears or trauma to the vagina, cervix, or uterus (from labor and delivery)
• Fragments of the placenta or amniotic sac that remain in the uterus after delivery
• The rupture of a C-section incision
• Blood clotting problems. A coagulation disorder can be an inherited condition or one that develops during pregnancy from complications such as severe preeclampsia, HELLP syndrome or a placental abruption. A hemorrhage can also cause clotting problems, leading to even heavier bleeding.

Postpartum hemorrhage treatment options

If you have a postpartum hemorrhage, you'll need to stay in the hospital until the bleeding is under control and your condition is stable. Your provider will examine you and try to determine the cause of the bleeding. There are a number of steps that your medical team may take while you're in the hospital:

Uterine massage. Your provider will massage your uterus by inserting one hand inside your vagina, placing their other hand on your belly, and gently compressing your uterus between their two hands. They'll also remove clotted blood and check for retained placenta, and remove it from inside your uterus to help it contract.

Intravenous fluids and medication and a catheter. You'll also be given intravenous fluids and medications to help the uterus contract and the bleeding stop. In most cases, the medication works very quickly. In rare cases (if the bleeding doesn't stop or your vital signs aren't stable), you'll get a blood transfusion.

Your provider may also insert a catheter to empty your bladder. (A full bladder makes it more difficult for your uterus to contract.)

Examination. Your provider will perform an exam to find the source of the bleeding. They will feel your uterus and look for lacerations that could be the source of the bleeding, as well as any fragments of the placenta that are still attached to your uterus. If the exam is uncomfortable or painful, you may be given pain medication. 

You may also have an ultrasound to check whether there are any pieces of placental tissue left in your uterus. If the bleeding or pain is too much for a clear evaluation, you may be transferred to the operating room so your doctor can do a more comprehensive pelvic exam (or other treatments) while you're under anesthesia.

Damage repair. You may need stitches to repair any tears or a procedure called dilation and curettage (D&C) to remove the remaining placenta. You may have a small "balloon" placed in your uterus. This creates pressure against the uterine walls to compress blood vessels and encourage blood clotting. It's usually left in overnight, along with a catheter to keep your bladder drained. Another way this can be done is with a device that creates a vacuum inside of the uterus, causing it to contract and closing off the open blood vessels.

Very rarely, abdominal surgery or a hysterectomy is necessary to stop a hemorrhage. (The risk of needing a hysterectomy is much higher if you have placenta previa or placenta accreta, or if you've had a previous C-section.)

After care. As part of routine postpartum care, your blood pressure and pulse will be taken regularly to help your provider gauge how your body is coping with the blood loss. An abnormally low blood pressure or high pulse can help your provider decide how to proceed with treating PPH.

After the bleeding is controlled, you'll continue to receive IV fluids and medication to help your uterus stay contracted, and your overall health will be monitored. 

You'll also have blood tests to check for anemia and, if necessary, to see whether your blood is clotting normally. You may need a blood transfusion or IV iron.

Postpartum hemorrhage recovery

In general, your recovery will depend on how much blood you lost and what your "reserves" were – that is, whether you were anemic before having a PPH. It's also possible to develop anemia from the blood loss. Keep in mind that you may feel weak and lightheaded at first, so be careful getting out of bed.

When you get home, it's important to get lots of rest, drink enough fluids to stay hydrated, and eat nutritious food. In addition to prenatal vitamins with folic acid, it's likely that your provider will prescribe an additional iron supplement to prevent or treat anemia caused by excessive blood loss.

Signs to watch out for after birth

Call your provider if you have bleeding that soaks more than one sanitary pad in an hour, or if you have blood clots bigger than a golf ball. Also get in touch right away if you develop new, significant bleeding after your initial postpartum bleeding slowed down or stopped.

Note: Call 911 if you're bleeding heavily and you have any signs of shock (see above).

Postpartum hemorrhage is one of the serious complications to be aware of after childbirth. Read about other postpartum warning signs.

Learn more:

• How long do you stay in the hospital after giving birth?
• How long does postpartum recovery last?
• What happens to your baby right after birth
• When will I get my first period after birth?

Visit the Society for Maternal-Fetal MedicineOpens a new window for more information.