Postpartum Haemorrhage

Postpartum haemorrhage is severe bleeding after childbirth that affects up to 5 in every 100 women, but with early detection and proper treatment, most people make a full recovery.

Table of contents

• What is postpartum haemorrhage?
• When does it occur?
• Signs and symptoms
• Why postpartum haemorrhage happens
• Who is at greater risk?
• Why early detection matters

What is postpartum haemorrhage?

Postpartum haemorrhage is severe or excessive bleeding that occurs after giving birth. It is a serious medical emergency that requires immediate treatment^[1]. The condition is defined as a cumulative blood loss (total amount of blood lost) of more than 1 liter after delivery, or blood loss that comes with signs of too little blood volume in the body, such as dizziness or a rapid heartbeat^[2][3].

To understand how much blood loss is normal, it helps to know that during a typical vaginal birth, a woman loses about 500 milliliters of blood (roughly half a quart), and during a cesarean birth (also called a C-section, which is surgery where the baby is born through a cut in the belly and womb), about 1,000 milliliters (or one quart)^[4]. With postpartum haemorrhage, you can lose much more blood, and this can happen very quickly.

When blood loss is severe, it causes a sharp drop in blood pressure, which restricts blood flow to vital organs like your heart, brain, and kidneys. When organs don’t get enough blood because of active bleeding, this dangerous condition is called hypovolemic shock, which can be deadly if not treated quickly^[1].

Postpartum haemorrhage occurs in about 1 to 5 of every 100 deliveries (1% to 5%)^[1]. It is one of the leading causes of maternal death worldwide, accounting for nearly one-quarter of all deaths related to pregnancy^[3]. In developed countries like the United States, it accounts for slightly more than 10% of maternal deaths^[3]. However, with prompt treatment, most cases are not life-threatening, and most people make a full recovery^[1].

When does it occur?

Postpartum haemorrhage is divided into two types based on when the bleeding happens^[1][5]:

• Primary postpartum haemorrhage occurs within the first 24 hours after delivery. This is the most common type, and most cases happen immediately after the baby is born.
• Secondary or late postpartum haemorrhage occurs from 24 hours after delivery up to 12 weeks after giving birth.

Most postpartum haemorrhage occurs right after delivery, often during or shortly after the delivery of the placenta (the organ that grows in the womb during pregnancy and provides food and oxygen to the baby)^[4].

Signs and symptoms

The most common sign of postpartum haemorrhage is persistent, heavy vaginal bleeding after delivery^[1]. This includes passing several large blood clots—anything larger than a golf ball may signal a problem^[1].

Other important signs to watch for include^[1][6]:

• Dizziness, blurred vision, or feeling faint
• Increased heart rate (your heart beating very fast)
• Pale or clammy skin
• Feeling weak or like you might pass out
• Decreased red blood cell count (measured through blood tests)
• Pain and swelling in the vaginal or perineal area (the area between the vagina and rectum), which can happen when blood collects outside of a blood vessel
• Chills
• Nausea (feeling sick to your stomach) or vomiting

It’s important to tell your healthcare providers about any concerning symptoms or changes you notice after delivery. In some cases, postpartum haemorrhage doesn’t cause symptoms until after you’ve left the hospital^[1]. Contact your healthcare provider immediately if you feel any of these symptoms in the days or weeks after giving birth.

Why postpartum haemorrhage happens

Understanding why postpartum haemorrhage occurs starts with knowing what normally happens after birth. During pregnancy, the placenta attaches to the wall of your womb. After your baby is born, your womb continues to contract (the womb muscles tighten) to deliver the placenta. These contractions also help compress and close the blood vessels where the placenta was attached to the wall of your womb. Sometimes, however, these contractions aren’t strong enough to stop the bleeding^[1].

Healthcare professionals often use a memory tool called the “Four T’s” to remember the most common causes of postpartum haemorrhage^[5][9]:

Tone: This refers to uterine atony, which means the womb muscle fails to contract properly after birth. This is the most common cause of postpartum haemorrhage, accounting for up to 80% of cases^[1][4]. When the womb doesn’t contract strongly enough, the blood vessels where the placenta was attached bleed freely and heavily.

Tissue: This involves problems with the placenta. Postpartum haemorrhage can happen if parts of the placenta or membranes (the sac that surrounds the baby) stay attached to the wall of the womb after delivery^[1][4]. The retained tissue prevents the womb from contracting effectively and leads to continued bleeding. Additionally, abnormal attachment of the placenta to the womb wall can cause severe bleeding.

Trauma: This refers to injuries to the birth canal or surrounding structures. During vaginal delivery, tears or cuts to the cervix (the opening of the womb), vagina, or perineum can cause significant bleeding^[5]. Operative deliveries using forceps or vacuum devices, or the use of episiotomy (a surgical cut made to enlarge the vaginal opening during birth), can increase the risk of trauma-related bleeding. During cesarean deliveries, injuries to blood vessels or organs in the abdomen and pelvis can also contribute to bleeding.

Thrombin: This refers to problems with blood clotting. Some women have coagulopathies (conditions that affect the blood’s ability to clot) that existed before pregnancy or were acquired during pregnancy^[5]. Pre-existing conditions might include von Willebrand disease or idiopathic thrombocytopenic purpura (a disorder where the immune system destroys blood-clotting cells). Coagulopathies acquired during pregnancy can include disseminated intravascular coagulation (a serious condition where blood clots form throughout the body), which may occur as a complication of other emergencies during pregnancy.

Who is at greater risk?

While postpartum haemorrhage can happen to any woman, some people are at higher risk than others. However, it’s crucial to know that 20% of postpartum haemorrhage occurs in women with no identified risk factors at all^[9]. This means healthcare providers must be prepared to manage this condition at every delivery.

Risk factors that may increase the chance of postpartum haemorrhage include^[4][7][9]:

• Placental abruption: This is when the placenta detaches from the womb too early, before the baby is born.
• Placenta previa: This is when the placenta covers or is very close to the cervical opening.
• Overdistended womb: This means the womb is larger than normal, which can happen because of too much amniotic fluid (the liquid that surrounds the baby in the womb) or a very large baby, especially one weighing over 4,000 grams (8.8 pounds).
• Multiple pregnancy: Carrying more than one baby, such as twins or triplets.
• Having had many previous births
• Prolonged labor or very rapid labor
• Bleeding during pregnancy
• Infection in the womb
• High blood pressure disorders during pregnancy
• Maternal obesity
• Maternal anemia (low red blood cell count)
• First-time mothers
• Use of certain medications during labor, such as prolonged use of oxytocin
• Having had postpartum haemorrhage in a previous pregnancy

Women identified as having a high risk of haemorrhage are usually advised to have their baby in a hospital setting where specialized care and resources are immediately available^[6].

Why early detection matters

Bleeding excessively after giving birth can be frightening and traumatic. You probably didn’t expect your birth experience to go this way^[1]. However, it’s critical to understand that early detection and prompt treatment are key to a full recovery.

Currently, one of the major challenges in responding to postpartum haemorrhage is that it is often detected too late. Most healthcare providers use visual inspection to assess bleeding, which tends to underestimate blood loss and can result in delayed recognition of the problem^[17]. This is why it’s so important to share any concerns about excessive bleeding after delivery with your healthcare provider so they can identify signs of postpartum haemorrhage as soon as they occur.

With postpartum haemorrhage, you can lose large amounts of blood very quickly. The labor and delivery team needs to find and stop the bleeding as rapidly as possible^[1]. Staff should keep you and your birth partner informed of what is happening at all times^[6].

The good news is that most cases of postpartum haemorrhage are treatable. In the majority of cases, heavy bleeding will settle with simple measures^[6]. Prompt treatment can prevent serious complications and save lives. With early detection and appropriate care, most people make a full recovery and can look forward to a healthy future with their families^[1].

Once you have recovered, you should be offered an opportunity to discuss what happened, and you can ask for further support from your healthcare team^[6].