Postpartum hemorrhage (PPH)

Postpartum hemorrhage

Excessive bleeding after birth is called postpartum hemorrhage (PPH). The most common cause of postpartum hemorrhage is uterine atony, which means the uterus does not contract normally after birth. Postpartum hemorrhage is a medical emergency and women who experience this will be given IV fluids and medications to help control the bleeding.

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Is postpartum bleeding normal?

Some postpartum bleeding is normal. All new moms have some vaginal bleeding and discharge immediately after giving birth, as the placenta begins to separate from the uterus. 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 stopping the bleeding. (You may also bleed from an episiotomy or tear you get during childbirth.)

This type of 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 days. Your body is well prepared to deal with a certain amount of blood loss because your total blood volume increases by almost 50 percent during pregnancy.

Post-delivery, your provider may help your uterus contract by pressing firmly on your abdomen and you may also get a synthetic form of the hormone oxytocin (Pitocin), which can help your uterus contract. ጡት ማጥባት 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 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 percent of births in the United States. When it happens in the days or weeks after delivery, it’s a late (or delayed or secondary) PPH.

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. Your provider may also notice, when examining you after delivery, that your uterus is enlarged and soft, rather than firm.

You may also develop signs of shock, such as:

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

What causes postpartum hemorrhage?

The most common cause of PPH is when the uterus does not contract effectively after delivery. The uterus contacting after delivery is important 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 or uterine subinvolution.

Uterine atony is more likely to happen if:

  • You gave birth to a very large baby or multiples, or 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 laceration during labor and delivery
  • Fragments of the placenta or amniotic sac that remain in the uterus after delivery
  • The bursting of a cesarean incision
  • Coagulation problems. A blood clotting 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.

Risk factors for postpartum hemorrhage include:

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

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

What is late postpartum hemorrhage?

Between 0.2 and 2.5 percent of postpartum women develop severe bleeding between 24 hours and 12 weeks after childbirth. This is called a late postpartum hemorrhage – also known as a delayed or secondary postpartum hemorrhage. Late postpartum hemorrhages typically occur one to two weeks postpartum.

The most common causes of late postpartum hemorrhage are:

  • Retained fragments of the placenta or membranes of the amniotic sac
  • Subinvolution of the placenta
  • Infection

Postpartum hemorrhage: Treatment options

If you do have a postpartum hemorrhage, you’ll need to remain hospitalized 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:

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. If you continue to bleed, you’ll be transferred to the operating room and given pain medication. Your provider will do another pelvic exam (perhaps under anesthesia) to check 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. You may also have an ultrasound to check if there are any pieces of placental tissue left in your uterus.

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.

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. 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 be watched very closely to make sure the bleeding doesn’t resume.

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 the PPH.

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.

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 at the beginning.

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 bright red bleeding that lasts longer than a few days after delivery, 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 profusely 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.

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