Postpartum hemorrhage

Postpartum hemorrhage (PPH) is a cumulative blood loss of more than 1000 mL with signs and symptoms of hypovolemia within 24 hours during labor and delivery, no matter how the baby was born. While blood loss after delivery is often underestimated, blood loss greater than 500 mL should be considered abnormal and may require intervention.

Last Updated: February 26, 2024

Bleeding in the first 24 hours after delivery is called primary postpartum hemorrhage, while bleeding between 24 hours and 12 weeks following delivery is called secondary postpartum hemorrhage.

Bleeding is the most common cause of maternal death and disability after giving birth. The incidence of PPH ranges from 1% to 6% of all deliveries. Seventy percent to eighty percent of all uterine hemorrhages are caused by uterine atony, the most common cause of PPH.

Uterine atony, or ineffective uterine contraction, is the leading cause of postpartum bleeding. Uterine atony is a primary cause of PPH, other primary causes include genital tract lacerations, retained placenta, and uterine inversion. In contrast, retained products of conception, infection, and subinvolution of the placental site are secondary causes. 

Heavy, uncontrollable bleeding that does not stop after giving birth is the primary sign of postpartum hemorrhage. Other PPH symptoms include:

  • Signs of hypotension include lightheadedness, blurred vision, and fainting;
  • Increased heart rate;
  • Low red blood cells count;
  • Cold and clammy skin;
  • Nausea or vomiting;
  • Persistent or increasing discomfort in the belly or pelvis.

In the event of a genital injury, it is important to check for bruising, bleeding, and uterine rupture as soon as possible. The evaluation may involve a manual examination and removal of any residual placental tissue or a bedside ultrasound. Uterine atony typically manifests as a loose, "boggy," or uncontracted uterus.

A type and screen or crossmatch may be prescribed if a blood transfusion is being considered. Lab findings often lag behind the clinical presentation, so a complete blood count at regular intervals is necessary to check hemoglobin, hematocrit, and platelet levels. For a more detailed picture, ultrasound is also used to see the uterus and other organs.

 

Treatment

In most cases, PPH is considered an emergency. The goals of managing postpartum hemorrhage include locating the source of the bleeding as quickly as possible and restoring blood volume. Below are some of the ways to prevent and restore blood volume

  • Drugs that cause contractions to occur, such as oxytocin, misoprostol, and carboprost;
  • Extraction of retained placental tissue from the uterus;
  • Tying arteries to cut off blood flow;
  • Applying pressure on the uterine walls with the aid of a catheter or balloon;
  • Blood transfusion.

The best strategy to prevent postpartum hemorrhage is to identify people who are at high risk before birth. This success depends on the patient's honesty with their doctor about their symptoms and medical history. Ensuring proper iron consumption and red blood cell counts throughout pregnancy can help reduce the severity of postpartum hemorrhage.

References

Wormer KC, Jamil RT, Bryant SB. Acute Postpartum Hemorrhage. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499988/

Cleveland Clinic (2022). Postpartum Hemorrhage (PPH). Retrieved November 4, 2022, from https://my.clevelandclinic.org/health/diseases/22228-postpartum-hemorrhage

Mayo Clinic (2022). Postpartum Hemorrhage (PPH). Retrieved November 4, 2022, from https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/postpartum-complications/art-20446702

Last Updated: February 26, 2024