Postpartum hemorrhage (PPH) is excessive bleeding after the birth of a baby. About 1 to 5 percent of women experience postpartum hemorrhage, and it is more likely to occur with a cesarean delivery. Most bleeding occurs after the placenta is delivered. The average amount of blood loss after the birth of a baby in a vaginal delivery is about 500 ml. The average blood loss for a cesarean delivery is about 1,000 ml. Most postpartum hemorrhage occurs right after the birth, but it can also happen later.
What is postpartum hemorrhage?
Postpartum hemorrhage (PPH) is heavy bleeding after childbirth. It is a serious and dangerous complication that requires immediate treatment. PPH usually occurs within 24 hours of giving birth, but it can occur up to 12 weeks after giving birth. With PPH, you lose a large amount of blood very quickly.
This causes a severe drop in blood pressure, limiting blood flow to your heart, brain, and other organs. When organs don’t get enough blood flow due to active bleeding, it’s called hypovolemic shock, which can be fatal. The birth team needs to find and stop the bleeding as quickly as possible.
Excessive bleeding after childbirth can be scary and traumatic. It’s important to discuss any concerns about excessive bleeding after birth with your prenatal care provider so they can identify signs of PPH as soon as they appear. With early diagnosis and prompt treatment, most people make a full recovery. Most PPH happens right after delivery.
Postpartum hemorrhage occurs in about 1 to 5 out of every 100 deliveries (1% to 5%), and most cases are not life-threatening with prompt treatment.
How much blood loss is considered postpartum hemorrhage?
PPH is excessive bleeding after childbirth, defined as ≥500 mL of blood loss after a vaginal delivery or ≥1,000 mL after a cesarean section or any blood loss causing hemodynamic instability. It is classified as primary PPH if it occurs within 24 hours of birth and secondary PPH if it happens between 24 hours and 6 weeks postpartum. The most common cause is uterine atony, where the uterus fails to contract effectively.
Symptoms
The following are the most common symptoms of postpartum hemorrhage. However, each woman may experience different symptoms. Symptoms may include:
- Uncontrolled bleeding
- Low blood pressure
- Rapid heart rate
- Low red blood cell count (hematocrit)
- Pain and swelling in the tissues of the vaginal and perineal area if the bleeding is due to a hematoma.
What causes postpartum hemorrhage?
After delivery, the uterus typically continues to contract and expel the placenta. These contractions help compress the bleeding vessels where the placenta is attached.
If the uterus does not contract strongly enough, called uterine atony, these blood vessels bleed freely, and bleeding occurs. Bleeding is also possible if small pieces of the placenta remain attached.
Some women are at higher risk of postpartum hemorrhage than others. Conditions that may increase the risk of postpartum hemorrhage include:
- Placental abruption: The premature separation of the placenta from the uterus.
- Placenta previa: The placenta covers or is near the opening of the cervix.
- Uterine hyperplasia: Excessive enlargement of the uterus due to excess amniotic fluid or a large baby, significantly if the baby weighs more than 4,000 grams at birth.
- Multiple pregnancy: more than one placenta and over-distension of the uterus.
- Gestational hypertension or preeclampsia
- Having had many previous deliveries
- Prolonged labor
- Infection
- Obesity
- Medications to induce labor
- Medications to stop contractions (for premature labor)
- Use of forceps or vacuum-assisted delivery
- General anesthesia
Postpartum hemorrhage may be due to other factors, including:
- Tearing of the cervix or vaginal tissues
- Tearing of a blood vessel in the uterus
- Bleeding into a tissue area or hidden space in the pelvis that becomes a hematoma
- Blood clotting disorders, such as disseminated intravascular coagulation
- Placenta accreta: The placenta is abnormally attached to the inside of the uterus.
- Placenta increta: Placental tissue invades the uterine muscle.
- Placenta percreta: Placental tissue extends to the end of the uterine muscle and may be lost.
How is postpartum hemorrhage diagnosed?
Diagnose postpartum hemorrhage through visual and physical examinations. Laboratory tests and a thorough health history may also be important to assess the risk and impact of PPH.
Postpartum hemorrhage is diagnosed based on the amount of blood you have lost. Counting or weighing blood-soaked pads or sponges after delivery is a common way to estimate blood loss.
Other tools that may be used to evaluate if there is concern about PPH include:
- Continuous monitoring of pulse rate and blood pressure to detect problems
- Blood tests to measure red blood cells (hematocrit) and blood clotting factors
- Pelvic exam to check the vagina, cervix, and uterus
- Ultrasound to get a detailed picture of the uterus
Treatment
Treatment of postpartum hemorrhage (PPH) focuses on stopping the bleeding, restoring blood volume, and addressing the underlying cause using the “Four Ts” approach:
1. Uterine Atony (Tone – Most Common Cause)
- Perform uterine massage to stimulate contractions.
- Administer uterotonic medications such as oxytocin (first-line), misoprostol, carboprost (Hemabate), or methylergonovine (Methergine).
- If bleeding persists, use a uterine balloon tamponade (e.g., Bakri balloon).
2. Trauma (Lacerations, Uterine Rupture, or Inversion)
- Repair vaginal, cervical, or uterine lacerations surgically.
- If uterine inversion occurs, manually reposition the uterus.
3. Retained Placental Tissue (Tissue)
- Manually remove any retained placental fragments.
- Perform dilation and curettage (D&C) if necessary.
4. Coagulopathy (Thrombin Disorders)
- Administer blood transfusions if there is significant anemia.
- Provide fresh frozen plasma, platelets, or cryoprecipitate for clotting disorders.
- Treat underlying conditions like disseminated intravascular coagulation (DIC) or HELLP syndrome.
If bleeding remains uncontrolled, advanced interventions such as uterine artery embolization, B-Lynch sutures, or hysterectomy may be required. Rapid, coordinated care is essential to prevent severe complications and ensure maternal stability.
Recovery from postpartum hemorrhage (PPH) varies depending on the severity of blood loss, the treatment received, and the mother’s overall health. Mild cases may resolve within a few days to a few weeks, while severe cases requiring blood transfusions or surgery may take weeks to months to recover fully.
Recovery
- First few days: Fatigue, dizziness, and weakness due to blood loss are common. Hydration and Iron supplements help with recovery.
- 2 to 6 weeks: The body gradually restores blood volume and strength. Close monitoring for anemia and delayed postpartum complications is essential.
- Several months: In severe cases, full recovery from anemia and surgical interventions may take 3 to 6 months, requiring ongoing medical care and nutritional support.
Regular follow-ups with a healthcare provider help ensure proper recovery and prevent complications such as anemia, infection, or delayed uterine torsion.
The bottom line
If you experience heavy bleeding after childbirth, seek medical attention immediately. Other signs of postpartum hemorrhage include dizziness, weakness, and shortness of breath. This is a serious condition that requires urgent medical care to prevent complications.
Experiencing postpartum hemorrhage can be overwhelming and even traumatic. Feeling scared or anxious is completely understandable if you or a loved one has gone through it. Early diagnosis and prompt treatment are key to ensuring a safe recovery.
Discussing your medical history with your healthcare provider is essential, as it can help determine if you’re at a higher risk for postpartum hemorrhage. Dr. Arjang Naim is here to provide expert care and support for your postpartum health needs.
Additional questions
- How long is the maximum number of days of postpartum bleeding?
You should see less bleeding after about 10 days. You may have light bleeding or spotting for up to 6 weeks after giving birth.
- What are the three stages of postpartum bleeding?
- Lochia Rubra (Days 1-4): Heavy, bright red bleeding with small clots.
- Lochia Serosa (Days 4-10): Lighter pink or brown discharge.
- Lochia Alba (Days 10-6 weeks): Yellowish or white discharge that gradually stops.
- What are the 5 5 5 rules for postpartum?
The 5-5-5 rule for postpartum recovery suggests:
- First 5 days: Stay in bed and rest as much as possible.
- Next 5 days: Stay on the bed (or couch), limiting activity.
- Final 5 days: Stay near the bed, slowly resuming light tasks.
- What exercises can I do postpartum?
Postpartum exercises should be gentle and gradually increase in intensity. Here are some safe options:
- Pelvic Floor Exercises (Kegels)
- Deep Breathing with Abdominal Engagement
- Pelvic Tilts
- Walking
- What to eat to prevent postpartum hemorrhage?
A nutritious diet should include Foods rich in protein and iron, such as animal offals and innards, red meat, poultry, and seafood. These are important for recovery and making up for blood loss during delivery.
Resources
https://my.clevelandclinic.org/health/diseases/22228-postpartum-hemorrhage
https://www.pregnancybirthbaby.org.au/postpartum-haemorrhage
https://www.marchofdimes.org/find-support/topics/postpartum/postpartum-hemorrhage
