Giving birth is an extremely challenging process for a woman’s body. While many women have normal, uncomplicated deliveries, there are risks and potential complications that can occur. One of the most common and potentially dangerous complications that can happen after giving birth is postpartum hemorrhage.
What is postpartum hemorrhage?
Postpartum hemorrhage (PPH) is defined as excessive bleeding following childbirth. It occurs when a woman loses more than 500 ml of blood within the first 24 hours after delivery. Severe PPH is considered to be blood loss greater than 1000 ml within the same timeframe. There are two main types of PPH:
- Early PPH – excessive bleeding within the first 24 hours after birth
- Late PPH – excessive bleeding occurring 24 hours to 12 weeks postpartum
Early PPH accounts for most cases and is typically caused by the uterus not contracting down firmly enough after delivery. Late PPH is less common and is often related to retained tissue in the uterus, infection, or bleeding disorders.
What causes postpartum hemorrhage?
There are several potential causes of PPH:
- Uterine atony – Failure of the uterus to contract after birth, leading to bleeding from the placental site. This is the most common cause.
- Retained placenta – All or part of the placenta remaining attached to the uterine wall.
- Genital tract trauma – Lacerations of the vagina, cervix, perineum or uterus during delivery.
- Uterine inversion – The uterus turns inside out after delivery.
- Uterine rupture – A tear in the uterine wall.
- Hematologic disorders – Clotting or bleeding disorders increasing risk of hemorrhage.
Certain factors can increase a woman’s risk of developing postpartum hemorrhage. These include:
- Prolonged or difficult labor
- Operative vaginal delivery with forceps or vacuum
- Cesarean section
- Induction of labor
- Oxytocin use to induce/augment labor
- Very large baby (over 4000g)
- Excessive uterine distention (multiple gestation, polyhydramnios)
- Placenta previa or placental abruption
- Coagulation disorders
- History of previous PPH
How common is postpartum hemorrhage?
Postpartum hemorrhage is the leading cause of maternal mortality worldwide, accounting for around 100,000 deaths per year globally. In the United States, PPH occurs in approximately 3-5% of vaginal deliveries and 6-8% of cesarean deliveries.
Rates of postpartum hemorrhage have been increasing over recent decades as induction and cesarean rates have risen. Severe cases resulting in very heavy bleeding, transfusion, hysterectomy or death occur in about 1-2% of deliveries.
PPH rates by location:
| Location | PPH Rate |
|---|---|
| Global | 6% |
| United States | 3-8% |
| Canada | 5-8% |
| Europe | 3-8% |
| Australia | 7-12% |
Signs and symptoms of postpartum hemorrhage
The main sign of postpartum hemorrhage is excessive vaginal bleeding after birth. Other signs and symptoms can include:
- Soaking more than one pad per hour
- Passing large blood clots
- Pooling or splashing of blood when moving in bed
- Constant trickle of blood
- Lightheadedness
- Dizziness
- Increase in heart rate
- Low blood pressure
- Uterine pain
- Foul-smelling lochia (postpartum vaginal discharge)
Diagnosing postpartum hemorrhage
Postpartum hemorrhage is generally diagnosed based on visual estimation of blood loss and the mother’s symptoms. Care providers watch closely for excessive bleeding after birth and heavy, saturated pads. Other diagnostic steps may include:
- Physical examination to look for sources of bleeding, clots or a boggy uterus.
- Checking the uterus to ensure it is contracted.
- Evaluating vaginal tears, hematomas or rupture sites.
- Monitoring vital signs for drops in blood pressure and rises in heart rate.
- Blood tests to check hemoglobin and hematocrit levels.
- Coagulation studies if bleeding disorder is suspected.
- Ultrasound to identify retained placental fragments.
Treatment for postpartum hemorrhage
If postpartum hemorrhage is suspected after delivery, rapid treatment is essential to prevent severe blood loss and stabilize the mother. First line treatment focuses on contracting the uterus firmly to slow bleeding from the placental site. Steps include:
- Uterine massage – Rubbing the fundus to stimulate uterine contractions.
- Medications – Giving IV oxytocin, misoprostol, and sometimes methylergonovine to promote uterine contraction.
- Breastfeeding baby – This releases oxytocin to help the uterus contract.
If bleeding continues despite these measures, surgical interventions may be used:
- Balloon tamponade – Inserting a balloon catheter into the uterus and inflating it to apply pressure.
- Uterine packing – Packing gauze into the uterus to compress bleeding sites.
- Uterine artery ligation – Tying off arteries supplying the uterus.
- Hysterectomy – Surgical removal of the uterus as a last resort.
If bleeding is severe, blood transfusions, IV fluids, and oxygen may be given to stabilize the mother. Transfer to an intensive care unit is sometimes required.
Complications of postpartum hemorrhage
Without quick recognition and treatment, excessive postpartum bleeding can lead to serious complications such as:
- Hypovolemic shock – Severe drop in blood pressure and oxygen delivery.
- Disseminated intravascular coagulation (DIC) – Widespread clotting activation using up platelets and clotting factors.
- Acute renal failure.
- Adult respiratory distress syndrome.
- Hepatic dysfunction.
- Loss of fertility if hysterectomy is required.
- Maternal death.
Preventing postpartum hemorrhage
Although postpartum hemorrhage often comes on suddenly, there are some prevention strategies that can be used:
- Active management of third stage labor – Giving oxytocin after delivery, controlled cord traction, and uterine massage.
- Allow delayed cord clamping when feasible.
- Minimize operative vaginal deliveries when possible.
- Have emergency supplies ready.
- Identify and treat risk factors such as anemia or bleeding disorders.
- Encourage breastfeeding right after birth.
It is also essential that delivery facilities and personnel are prepared to act immediately at the first sign of excessive bleeding. Having protocols and drills in place allows rapid response.
Postpartum hemorrhage care guidelines
Management of postpartum hemorrhage generally follows standard protocols such as:
- Identify and declare PPH when blood loss > 500 ml.
- Massage uterus to stimulate contraction.
- Give medications: Oxytocin, misoprostol, methylergonovine.
- Start IV fluids, monitor vital signs.
- Perform any needed surgical interventions such as balloon tamponade, uterine packing, artery ligation, hysterectomy.
- Give blood transfusions as needed to stabilize hemoglobin.
- Transfer to higher level of care if bleeding is not controlled or mother is unstable.
- Watch for late PPH up to 12 weeks postpartum.
Following standardized management guidelines facilitates rapid and appropriate treatment when every minute counts.
Prognosis and outcomes for postpartum hemorrhage
With prompt recognition and treatment, most cases of postpartum hemorrhage can be treated successfully, and the mother will recover without long term effects. However, outcomes depend heavily on how quickly bleeding is identified and controlled.
Mild to moderate PPH with blood loss of 500-1000 ml usually has a good prognosis, with mothers stabilizing after treatment. Blood transfusions may be required.
Severe PPH with loss >1000 ml has a poorer prognosis. Despite transfusion and surgical measures, these cases are at high risk of complications such as organ failure and disseminated coagulation. Maternal death can occur in up to 6% of severe cases.
Overall, mortality rates from postpartum hemorrhage in developed countries are around 0.1%. However, in developing regions with limited access to care, PPH still accounts for up to one third of maternal deaths.
PPH prognosis by blood loss amount:
| Blood loss | Prognosis |
|---|---|
| 500-1000 ml | Usually stabilizes with treatment |
| >1000 ml | High risk of complications and mortality |
Effects of postpartum hemorrhage on breastfeeding
Postpartum hemorrhage can sometimes affect a woman’s ability to successfully breastfeed her newborn. Reasons include:
- Extreme fatigue slowing milk production.
- Difficulty coping due to hemorrhage trauma.
- Breast engorgement during recovery.
- Delayed lactogenesis from IV fluids and blood products.
- Poor let-down reflex if stressed.
- Decreased prolactin levels after blood transfusion.
- Low milk supply from pituitary damage (Sheehan’s syndrome) after severe hemorrhage.
However, mothers who wish to breastfeed are still encouraged to put baby to breast frequently, express milk, and seek lactation support. This helps maintain milk production during the recovery period. Most mothers can still successfully breastfeed after mild to moderate hemorrhage.
Emotional impact of postpartum hemorrhage
In additional to physical effects, postpartum hemorrhage can take a heavy emotional toll. Some common feelings include:
- Fear, anxiety, panic during the hemorrhage.
- Anger about what happened.
- Feeling out of control.
- Depression.
- Detachment from the baby.
- Flashbacks, nightmares.
- Poor bonding with the baby.
- Fear about future pregnancies.
- Post-traumatic stress disorder (PTSD).
Talking with supportive care providers, partners, and family can help mothers cope. Counseling or joining support groups may also help overcome trauma.
Preparing for next delivery after PPH
For women who wish to have more children after a postpartum hemorrhage, planning for a safer subsequent delivery is wise. Steps that can be taken include:
- Seeking care from a high-risk obstetrician.
- Delivering at a facility capable of managing hemorrhage.
- Optimizing health and nutrition before next pregnancy.
- Controlling conditions like anemia or bleeding disorders.
- Planning necessary interventions such as medication for labor, arterial line placement, etc.
- Choosing a planned cesarean if appropriate.
- Talking with a counselor about fears.
While there are no guarantees, advancing medical care and vigilance during labor can help reduce PPH risks in the future.
Conclusion
Postpartum hemorrhage is the leading cause of maternal mortality and morbidity around the globe. While frequently sudden and unexpected, PPH can often be managed successfully if identified immediately after birth. Prevention, early recognition, prompt treatment and standardized management protocols are key to optimizing outcomes and saving mothers’ lives after this common but potentially devastating complication.