Postpartum hemorrhage

Postpartum hemorrhage (also called PPH) is when a woman has heavy bleeding after giving birth. It’s a serious but rare condition. It usually happens within 1 day of giving birth, but it can happen up to 12 weeks after having a baby. About 1 to 5 in 100 women who have a baby (1 to 5 percent) have PPH.

It’s normal to lose some blood after giving birth. Women usually lose about half a quart (500 milliliters) during vaginal birth or about 1 quart (1,000 milliliters) after a cesarean birth (also called c-section). A c-section is surgery in which your baby is born through a cut that your doctor makes in your belly and uterus (womb). With PPH, you can lose much more blood, which is what makes it a dangerous condition. PPH can cause a severe drop in blood pressure. If not treated quickly, this can lead to shock and death. Shock is when your body organs don’t get enough blood flow.

When does PPH happen?

After your baby is delivered, the uterus normally contracts to push out the placenta.  The contractions then help put pressure on bleeding vessels where the placenta was attached in your uterus.  The placenta grows in your uterus and supplies the baby with food and oxygen through the umbilical cord. If the contractions are not strong enough, the vessels bleed more.  It can also happen if small pieces of the placenta stay attached. 

How do you know if you have PPH?

You may have PPH if you have any of these signs or symptoms. If you do, call your health care provider or 911 right away:

• Heavy bleeding from the vagina that doesn’t slow or stop
• Drop in blood pressure or signs of shock. Signs of low blood pressure and shock include blurry vision; having chills, clammy skin or a really fast heartbeat; feeling confused, dizzy, sleepy or weak; or feeling like you’re going to faint.
• Nausea (feeling sick to your stomach) or throwing up
• Pale skin
• Swelling and pain around the vagina or perineum. The perineum is the area between the vagina and rectum.

Are some women more likely than others to have PPH?

Yes. Things that make you more likely than others to have PPH are called risk factors. Having a risk factor doesn’t mean for sure that you will have PPH, but it may increase your chances. PPH usually happens without warning. But talk to your health care provider about what you can do to help reduce your risk for having PPH.

You’re more likely than other women to have PPH if you’ve had it before. This is called having a history of PPH. Asian and Hispanic women also are more likely than others to have PPH.

Several medical conditions are risk factors for PPH. You may be more likely than other women to have PPH if you have any of these conditions:

Conditions that affect the uterus

• Uterine atony. This is the most common cause of PPH. It happens when the muscles in your uterus don’t contract (tighten) well after birth. Uterine contractions after birth help stop bleeding from the place in the uterus where the placenta breaks away. You may have uterine atony if your uterus is stretched or enlarged (also called distended) from giving birth to twins or a large baby (more than 8 pounds, 13 ounces). It also can happen if you’ve already had several children, you’re in labor for a long time or you have too much amniotic fluid. Amniotic fluid is the fluid that surrounds your baby in the womb.
• Uterine inversion. This is a rare condition when the uterus turns inside out after birth.
• Uterine rupture. This is when the uterus tears during labor. It happens rarely. It may happen if you have a scar in the uterus from having a c-section in the past or if you’ve had other kinds of surgery on the uterus.

Conditions that affect the placenta

• Placental abruption. This is when the placenta separates early from the wall of the uterus before birth. It can separate partially or completely.
• Placenta accreta, placenta increta or placenta percreta. These conditions happen when the placenta grows into the wall of the uterus too deeply and cannot separate.
• Placenta previa. This is when the placenta lies very low in the uterus and covers all or part of the cervix. The cervix is the opening to the uterus that sits at the top of the vagina.
• Retained placenta. This happens if you don’t pass the placenta within 30 to 60 minutes after you give birth. Even if you pass the placenta soon after birth, your provider checks the placenta to make sure it’s not missing any tissue. If tissue is missing and is not removed from the uterus right away, it may cause bleeding.

Conditions during labor and birth

• Having a c-section
• Getting general anesthesia. This is medicine that puts you to sleep so you don’t feel pain during surgery. If you have an emergency c-section, you may need general anesthesia.
• Taking medicines to induce labor.  Providers often use a medicine called Pitocin to induce labor. Pitocin is the man-made form of oxytocin, a hormone your body makes to start contractions.
• Taking medicines to stop contractions during preterm labor. If you have preterm labor, your provider may give you medicines called tocolytics to slow or stop contractions.
• Tearing (also called lacerations). This may happen if the tissues in your vagina or cervix are cut or torn during birth. The cervix is the opening to the uterus that sits at the top of the vagina. You may have tearing if you give birth to a large baby, your baby is born through the birth canal too quickly or you have an episiotomy that tears. An episiotomy is a cut made at the opening of the vagina to help let the baby out. Tearing also can happen if your provider uses tools, like forceps or a vacuum, to help move your baby through the birth canal during birth. Forceps look like big tongs. A vacuum is a soft plastic cup that attaches to your baby’s head. It uses suction to gently pull your baby as you push during birth.
• Having quick labor or being in labor a long time. Labor is different for every woman. If you’re giving birth for the first time, labor usually takes about 14 hours. If you’ve given birth before, it usually takes about 6 hours. Augmented labor may also increase risk of PPH. Augmentation of labor means medications or other means are used to make more contractions of the uterus during labor. 

Other conditions

• Blood conditions, like von Willebrand disease or disseminated intravascular coagulation (also called DIC). These conditions can increase your risk of forming a hematoma. A hematoma happens when a blood vessel breaks causing a blood clot to form in tissue, an organ or another part of the body. After giving birth, some women develop a hematoma in the vaginal area or the vulva (the female genitalia outside of the body). Von Willebrand’s disease is a bleeding disorder that makes it hard for a person to stop bleeding. DIC causes blood clots to form in small blood vessels and can lead to serious bleeding. Certain pregnancy and childbirth complications (like placenta accreta), surgery, sepsis (blood infection) and cancer can cause DIC.
• Infection, like chorioamnionitis. This is an infection of the placenta and amniotic fluid.
• Intrahepatic cholestasis of pregnancy (also called ICP). This is the most common liver condition that happens during pregnancy.
• Obesity. Being obese means you have an excess amount of body fat. If you’re obese, your body mass index (also called BMI) is 30 or higher. BMI is a measure of body fat based on your height and weight. To find out your BMI, go to www.cdc.gov/bmi.
• Preeclampsia or gestational hypertension. These are types of high blood pressure that only pregnant women can get. Preeclampsia is a condition that can happen after the 20th week of pregnancy or right after pregnancy. It’s when a pregnant woman has high blood pressure and signs that some of her organs, like her kidneys and liver, may not be working properly. Signs of preeclampsia include having protein in the urine, changes in vision and severe headache. Gestational hypertension is high blood pressure that starts after 20 weeks of pregnancy and goes away after you give birth. Some women with gestational hypertension have preeclampsia later in pregnancy.

How is PPH tested for and treated?

Your provider may use these tests to see if you have PPH or try to find the cause for PPH:

• Blood tests called clotting factors tests or factor assays
• Hematocrit. This is a blood test that checks the percent of your blood (called whole blood) that’s made up of red blood cells. Bleeding can cause a low hematocrit.
• Blood loss measurement. To see how much blood you’ve lost, your provider may weigh or count the number of pads and sponges used to soak up the blood.
• Pelvic exam. Your provider checks your vagina, uterus and cervix.
• Physical exam. Your provider checks your pulse and blood pressure.
• Ultrasound. Your provider can use ultrasound to check for problems with the placenta or uterus. Ultrasound is a test that uses sound waves and a computer screen to make a picture of your baby inside the womb or your pelvic organs.

Treatment depends on what’s causing your bleeding. It may include:

• Getting fluids, medicine (like Pitocin) or having a blood transfusion (having new blood put into your body). You get these treatments through a needle into your vein (also called intravenous or IV), or you may get some directly in the uterus.
• Having surgery, like a hysterectomy or a laparotomy. A hysterectomy is when your provider removes your uterus. You usually only need a hysterectomy if other treatments don’t work. A laparotomy is when your provider opens your belly to check for the source of bleeding and stops the bleeding.
• Massaging the uterus by hand. Your provider can massage the uterus to help it contract, lessen bleeding and help the body pass blood clots. Your provider may also give you medications like oxytocin to make the uterus contract and lessen bleeding.
• Getting oxygen by wearing an oxygen mask
• Removing any remaining pieces of the placenta from the uterus, packing the uterus with gauze, a special balloon or sponges, or using medical tools or stitches to help stop bleeding from blood vessels.
• Embolization of the blood vessels that supply the uterus. In this procedure, a provider uses special tests to find the bleeding blood vessel and injects material into the vessel to stop the bleeding. It’s used in special cases and may prevent you from needing a hysterectomy.
• Taking extra iron supplements along with a prenatal vitamin may also help. Your provider may recommend this depending on how much blood was lost.

See also: Maternal death

Last reviewed March 2020