McKesson Clinical Reference Systems: Women's Health Advisor 2002.2

What is severe postpartum bleeding?

Severe postpartum bleeding is the loss of more than a pint of blood within the first 24 hours after delivering a baby. It is also called a postpartum hemorrhage. It is not normal to lose this much blood after delivery.

How does it occur?

Some reasons for severe bleeding after childbirth include:

• The uterus stays relaxed and does not contract after delivery of the baby and placenta.
• The placenta is not completely removed from the uterus.
• There are cuts or tears in the vagina, cervix (opening to the uterus), or genital tract.
• You have blood-clotting problems.

Some women hemorrhage as late as 5 to 14 days after delivery. The most common reasons for this late severe bleeding are:

• failure of the uterus to contract enough
• pieces of placenta left in the uterus
• infection of the placenta insertion site
• a collection of blood in the tissues of the genital tract, called a hematoma
• 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 four previous deliveries
• fibroids, scars, or defects of the uterus
• blood clotting problems
• a distended uterus from a large baby, twins, or too much fluid
• induced labor and the use of oxytocin to stimulate 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 immediately after the baby is born. If the blood loss is not treated, later signs include a rapid pulse, low blood pressure, and shock.

How is it diagnosed?

After an exam, the following tests may be necessary:

• a complete blood count
• tests of blood clotting
• kidney function studies
• blood type and antibody screen if the mother needs a transfusion.

How is it treated?

If you are at increased risk of postpartum hemorrhage or have had a postpartum hemorrhage, your doctor 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.
• Get blood samples to test.
• 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, the doctor will try to take the placenta out with his or her hand. If the placenta is already out, the doctor will try to make the uterus contract by massaging the uterus. If massaging doesn't work, the doctor will give you more drugs to stimulate contraction. If the uterus is still bleeding, you may be given anesthesia so the doctor 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, the doctor 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 doctor may:

• Give you IV fluids.
• Give you oxytocin or other medication 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.

This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.