The hardest part for many new moms who recently gave birth is behind them. Unfortunately, however, some women experience postpartum hemorrhage after delivery. Some blood loss during and after delivery is expected. Women’s bodies are designed and prepared to lose blood immediately after pregnancy. This is part of why blood volume increases by 45 percent during pregnancy. Women gain an average of 1,200 to 1,600 milliliters of blood during pregnancy.1
However, this is considered postpartum hemorrhage (PPH) when blood loss becomes excessive. PPH is relatively rare; 1 percent to 5 percent of women experience it. Despite its relative rarity, PPH can be severe and traumatic. Here we will define postpartum hemorrhage and look at its causes, prevention, treatment, and recovery.2
What is Postpartum Hemorrhage?
The American College of Obstetricians and Gynecologists defines postpartum hemorrhage as blood loss of one liter or more. Blood loss between a half and a whole liter is sometimes termed “less severe blood loss.”3,4
Postpartum hemorrhage is divided into primary/early and secondary/late postpartum hemorrhage (PPH). Primary or early PPH occurs within the first 24 hours after the delivery of your baby, and this can happen even before the placenta is delivered. Secondary or late PPH can occur between 24 hours postpartum through 12 weeks after delivery.5
Even if less than a liter of blood is lost, postpartum blood loss can be considered a hemorrhage if the woman experiences symptoms of low blood volume.3
Diagnosis of Postpartum Hemorrhage
Your provider should be monitoring your blood loss throughout labor and delivery. This can be done using an under-buttocks drape to catch the blood that comes out during pushing and immediately after delivery. They may also weigh blood-soaked pads, sponges, and clots to estimate lost volume. If cumulative blood loss totals 1,000 milliliters or more, your provider should identify its source and cause.4
If you have lost less than a liter of blood but experience symptoms of PPH, you may also be diagnosed with and treated for hemorrhage.
Symptoms of Postpartum Hemorrhage
There are many signs of postpartum hemorrhage to look out for besides the quantity of blood lost.
The first sign of postpartum hemorrhage is often tachycardia or a rapid heart rate. This is why your healthcare team will monitor your vital signs frequently, especially in the first 24 hours. They want to catch any signs of hemorrhage early to stop the bleeding, intervene, and treat it if necessary.4
Women with PPH may also experience hypotension, or low blood pressure, particularly when going from lying to sitting or sitting to standing. This is called orthostatic hypotension. Low blood pressure can result from low blood volume due to hemorrhage. Low blood volume from a postpartum hemorrhage may also cause other symptoms, including nausea, painful breathing or chest pain, and decreased urine output.4
Although most cases of PPH occur within 24 hours while most women are still in the hospital, PPH can occur up to 12 weeks postpartum. If you are experiencing any of these symptoms within this time frame, contact your provider immediately.
Postpartum Hemorrhage Risk Factors
Some risk factors increase your chances of having a postpartum hemorrhage. These include:
History of Postpartum Hemorrhage
If you have experienced postpartum hemorrhage, you will likely have it again. Some doctors say that it is likely to worsen with each birth.2
A uterus that is extra stretched due to twins, a particularly large baby, or excess amniotic fluid puts you at an increased risk for PPH.6
Long or Short Labor
Every woman’s labor is different, but, on average, first-time moms can expect to be in labor for around 14 hours, whereas moms who have given birth before can expect about six hours of active labor. Very short or very long labor can increase a woman’s risk for PPH.2
Even if labor is not excessively long, a prolonged pushing stage can put you at risk for PPH. The pushing stage is prolonged if you push for more than 2-3 hours.6
Labor Induction or Augmentation
If you have an induced labor or are helped with medication, this may also increase your risk for PPH. This is particularly true if you experienced prolonged Pitocin use of greater than 12 continuous hours.2,6
Having a C-section or a history of other uterine surgery increases your risk for PPH.2
Being diagnosed with a placental issue in which the placenta grows too deeply into the uterus, such as accreta, percreta, or increta, may mean you’re at higher risk for hemorrhage. Placenta previa, where the placenta partially or fully covers the cervix, or placental abruption, where the placenta prematurely attaches from the uterine wall, also increases your risk for PPH.6
There are many other risk factors for postpartum hemorrhages, such as uterine infection, fibroids, certain medications, and preexisting blood conditions.6
While many of these conditions and circumstances increase your risk for PPH, about half of all postpartum hemorrhages occur in women with no identified risk factors.6
Causes of Postpartum Hemorrhage
There are four leading causes of PPH.
Uterine atony causes about 70 percent of postpartum hemorrhages. Uterine atony is when the uterus does not contract back down to its original size after delivery.4
Trauma during delivery, such as vaginal tears, cause another 20 percent of postpartum hemorrhages.4
Retained placenta or a clot in the uterus after delivery causes 10 percent of hemorrhages.4
About 1 percent of postpartum hemorrhages are caused by issues with getting blood to clot.4
Postpartum Hemorrhage Prevention and Treatment
Your provider may implement different techniques to prevent excessive bleeding and stop any bleeding that does occur immediately. Some of these strategies include:
With your permission, your provider may gently tug on the umbilical cord after birth to help deliver the placenta more quickly and decrease total maternal blood loss. Cord traction likely does not reduce the risk of severe postpartum hemorrhage but may reduce the incidence of less severe blood loss between 500 and 1,000 milliliters.4,7
Your provider may request to massage your uterus, either externally or internally. This is thought to stimulate uterine contractions and decrease blood loss. However, this intervention is unproven.8
Your provider may administer medications that help the uterus contract to prevent or treat postpartum hemorrhage. Some of these medications include Pitocin, Hemabate, Methergine, and Misoprostol.4
If your blood loss totals more than 1,500 milliliters, your provider will likely do a blood transfusion to prevent more severe complications from bleeding. Hospital personnel will probably ask you to sign a consent form stating that you would accept donor blood products in case of an emergency.9
Recovery After Postpartum Hemorrhage
After a postpartum hemorrhage, you may feel weak, and your provider may recommend limiting your activity. This will help you recover and prevent you from falling due to weakness and lightheadedness.
Even if you get a blood transfusion to treat your postpartum hemorrhage, you may not receive as much blood as you lost, so it will take at least a few weeks for your body to rebuild its blood supply.10
To aid in your recovery, eat a healthy diet and stay hydrated. Get as much rest as possible, though that is not always easy with a newborn! Finally, your provider may recommend an iron supplement to help you rebuild your blood supply.11
Postpartum hemorrhage can be scary and traumatic. Be sure to contact your provider or a mental health professional if you or your partner are having trouble processing what happened.
Since PPH is sometimes very significant, you may not get the immediate bonding opportunity with your newborn as medical professionals stabilize you. This can contribute to post-traumatic stress, depression, and anxiety. Watch for signs of these conditions and get the treatment you need.12
PPH can also lead to long-term physiological complications if not caught and treated appropriately. Being under the care of a trusted provider can make all the difference.
The days and weeks after having a baby can be a big adjustment and challenging, even without complications like postpartum hemorrhage. Be sure to accept help, get your rest, take care of yourself, process your birth, and bond with your new baby. All of this can lead to a better recovery.