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Postpartum Hemorrhage

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Definition

Postpartum hemorrhage is excessive blood loss in a woman after childbirth. It is called primary when it is within the first 24 hours after childbirth. Secondary (or delayed) postpartum hemorrhage occurs between 24 hours to six weeks after childbirth.

Some blood loss is normal. However, postpartum hemorrhage is a potentially serious condition that often goes unrecognized. Any excessive blood loss can put a woman at considerable risk. Talk with your doctor if you have any concerns about blood loss after giving birth.

Postpartum Hemorrhage
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Causes

Postpartum hemorrhage can be caused by:

  • A loss of muscle tone in the uterus after birth
  • Wounds in the birth canal
  • Failure to deliver the placenta
  • Maternal bleeding disorders that prevent blood clotting (rare)

In rare cases, uterine inversion or uterine rupture may also cause postpartum hemorrhage.

Risk Factors

Postpartum hemorrhage may be more common in Asian and Hispanic women.

Factors leading up to labor that may increase your chance of postpartum hemorrhage include:

  • History of previous postpartum hemorrhage
  • Pre-eclampsia
  • Problems with the placenta
  • Obesity
  • First pregnancy
  • Multiple pregnancy, which may create high amniotic fluid levels

Complications of labor and delivery that may increase your chance of postpartum hemorrhage include:

  • Interventions, such as:
    • Augmented labor—methods that stimulate or speed the progression of labor when it is delayed or stopped
    • Forceps or vacuum delivery
    • Episiotomy
    • Cesarean section
  • Prolonged labor
  • Large fetus
  • Chorioamnionitis—a bacteria infection of the membranes and fluid surrounding the fetus
  • Stillbirth
Demonstration of Forceps and Vacuum Delivery
Vacuum and forceps delivery
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Signs and Symptoms

The most obvious sign of postpartum hemorrhage is heavy vaginal bleeding. If the bleeding is not obvious, other signs may include:

  • Lightheadedness and fainting
  • Increased heart rate
  • Decreased blood pressure
  • Swelling and pain in the vaginal and perineal area

Diagnosis

Your doctor will ask about your symptoms. A physical exam will be done. The doctor will check your perineum, vagina, cervix, and uterus for bleeding. Other tests may include:

  • Blood tests
  • Blood clotting tests
  • Clot observation tests
  • Monitoring the number of saturated pads or sponges that absorb blood
  • Monitoring blood pressure and pulse

Imaging tests take pictures of internal body structures. Imaging tests may include:

Treatment

Treatment is based on the severity of bleeding. Treatment options include:

Fluids, Oxygen, and/or Resuscitation

You may need IV fluids or an oxygen mask. In severe cases, resuscitation or a blood transfusion may be necessary.

Bimanual Uterine Massage

A massage technique called bimanual uterine massage can control bleeding. A doctor or nurse will place one hand in your vagina to push on your uterus, while the other hand pushes down on your abdomen. This action will cause a relaxed uterus to contract, thus slowing bleeding.

Trauma Repair

Bleeding can be caused by a tear in your genital tract or other trauma. The tear will be stitched. In addition, tissue from a retained placenta may need to be removed.

Medications

Your doctor may prescribe uterotonics or prostaglandins to stimulate contraction of the uterus.

Surgery

In some cases, surgery may be needed to stop bleeding. Procedures include:

  • Uterine packing—sterile materials or a special tamponade device is placed inside the uterine cavity to compress the bleeding area
  • Repair of arteries
  • Uterine curettage—scraping the lining of the uterus
  • Repair of hematoma
  • Removal of retained placenta
  • Uterine artery embolization—non-invasive procedure to block the uterine artery
  • Hysterectomy—removal of the uterus

Prevention

To help reduce your chance of developing postpartum hemorrhage, take these steps:

  • Receiving continuous nursing care during labor
  • Make sure you are closely monitored during the third stage of labor, when the placenta is delivered

Revision Information

  • American Congress of Obstetricians and Gynecologists

    http://www.acog.org

  • American Pregnancy Association

    http://www.americanpregnancy.org

  • Health Canada

    http://www.hc-sc.gc.ca

  • Women's Health Matters

    http://www.womenshealthmatters.ca

  • American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006;108(4):1039-1047. Reaffirmed 2011.

  • Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007;75(6):875-882.

  • Postpartum hemorrhage. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed.ebscohost.com/about/about-us. Updated July 19, 2013. Accessed August 6, 2013.