Severe Postpartum Bleeding (Postpartum Hemorrhage)

What is severe postpartum bleeding?

Severe postpartum bleeding is the loss of more than a pint of blood usually right after delivery or within the first 24 hours after delivering a baby. It is also called a postpartum hemorrhage.

How does it occur?

Some of the causes of severe bleeding after childbirth are:

• The uterus stays relaxed and does not contract after delivery of the baby and placenta.
• Pieces of the placenta are left in the uterus.
• There are cuts or tears in the vagina, uterus, or cervix (opening to the uterus).
• There is bleeding from the cut made in the uterus for a C-section.
• You have an infection in the uterus.
• There is a collection of blood in the tissues of the genital tract, called a hematoma.
• You have blood-clotting problems.

If you have any of the following problems, you are at risk for postpartum hemorrhage:

• a hemorrhage with a previous pregnancy
• more than 4 previous deliveries
• fibroids, scars, or defects of the uterus
• blood clotting problems
• a uterus that has become very large from a large baby, twins, or too much fluid in the uterus
• the extended use of oxytocin to induce labor
• a long labor (longer than about 18 hours)
• separation of the placenta from the uterus before delivery
• an infection of the uterus

What are the symptoms?

The first sign of hemorrhage is excessive bleeding, usually right after the baby is born. Some women hemorrhage as late as 5 days to 6 weeks after delivery. If the blood loss is not treated, later signs and symptoms include a rapid pulse, low blood pressure, weakness, fainting, and shock.

How is it diagnosed?

After an exam, the following tests may be necessary:

• blood tests
• ultrasound scan

How is it treated?

If you are at increased risk of postpartum hemorrhage or have had a postpartum hemorrhage, your healthcare provider may:

• Give fluids intravenously (IV) to replace lost fluids and keep the blood pressure up.
• Give drugs by shot or in an IV to help the uterus contract after delivery of the placenta.
• Have blood available in case a blood transfusion is necessary.

If you are bleeding and the placenta does not come out after the baby is born, your provider will try to take the placenta out with his or her hand. If the placenta is already out, your provider will try to make the uterus contract by massaging the uterus. If massaging doesn't work, your provider will give you more drugs to stimulate contraction. If the uterus is still bleeding, you may be given anesthesia so your provider can explore the inside of the uterus and vagina for tears or pieces of placenta and repair any bleeding areas that are found.

If the bleeding continues when the uterus is firm or contracted, your provider may:

• Examine you for cuts or tears in the lower genital tract.
• Treat you for blood clotting problems if no cuts or tears are found.
• Use surgery to look inside your abdomen for the cause of bleeding.

A complication of postpartum hemorrhage is hypovolemic shock. You can lose a lot of blood during delivery of a baby and not go into shock. However, if the blood loss is rapid and excessive and the blood is not replaced quickly, you can go into shock. Your blood pressure will drop and your heart will beat faster. If shock is severe or not properly treated, it can lead to serious problems.

The treatment for hypovolemic shock is to give you fluid or blood transfusions to replace the lost blood. You may require intensive care until your condition is stable.

If you have severe bleeding later after birth, your treatment will be similar to the treatment for a hemorrhage that occurs soon after delivery. Your healthcare provider may:

• Give you IV fluids.
• Give you oxytocin or other medicine to contract the uterus.
• Give you antibiotics to prevent or treat infection.
• Scrape the uterus to remove any retained placenta.
• Perform surgery to find the site of bleeding or remove or repair the cause of bleeding.

How can I help take care of myself?

• Follow your healthcare provider's recommendations.
• Do not become too active too soon at home after delivery. Get extra help, if necessary.
• Call your provider right away if you have a lot of vaginal bleeding, especially if you have blood clots, when you are home from the hospital.

How can I help prevent postpartum hemorrhage?

There is no sure way to prevent postpartum hemorrhage. You can help keep your uterus healthy if you:

• Do not start having sexual intercourse again until your uterus is fully contracted back to its normal size. This usually takes at least 6 weeks after delivery.
• Do not do any heavy or prolonged work or lifting until your uterus is back to its normal size.