What is postpartum hemorrhage?
Postpartum hemorrhage is excessive bleeding following the birth of a baby. About 1% to 5% of women have postpartum hemorrhage and it is more likely with a cesarean birth. Hemorrhage most commonly occurs after the placenta is delivered. The average amount of blood loss after the birth of a single baby in vaginal delivery is about 500 ml (or about a half of a quart). The average amount of blood loss for a cesarean birth is approximately 1,000 ml (or one quart). Most postpartum hemorrhage occurs right after delivery, but it can occur later as well.
What causes postpartum hemorrhage?
Once a baby is delivered, the uterus normally continues to contract (tightening of uterine muscles) and expels the placenta. After the placenta is delivered, these contractions help compress the bleeding vessels in the area where the placenta was attached. If the uterus does not contract strongly enough, called uterine atony, these blood vessels bleed freely and hemorrhage occurs. This is the most common cause of postpartum hemorrhage. If small pieces of the placenta remain attached, bleeding is also likely.
Some women are at greater risk for postpartum hemorrhage than others. Conditions that may increase the risk for postpartum hemorrhage include the following:
Placental abruption. The early detachment of the placenta from the uterus.
Placenta previa. The placenta covers or is near the cervical opening.
Overdistended uterus. Excessive enlargement of the uterus due to too much amniotic fluid or a large baby, especially with birthweight over 4,000 grams (8.8 pounds).
Multiple pregnancy. More than one placenta and overdistention of the uterus.
Gestational hypertension or preeclampsia. High blood pressure of pregnancy.
Having many previous births
Medications to induce labor
Medications to stop contractions (for preterm labor)
Use of forceps or vacuum-assisted delivery
Postpartum hemorrhage may also be due to other factors including the following:
Tear in the cervix or vaginal tissues
Tear in a uterine blood vessel
Bleeding into a concealed tissue area or space in the pelvis which develops into a hematoma, usually in the vulva or vaginal area
Blood clotting disorders, such as disseminated intravascular coagulation
Placenta accreta. The placenta is abnormally attached to the inside of the uterus (a condition that occurs in one in 2,500 births and is more common if the placenta is attached over a prior cesarean scar).
Placenta increta. The placental tissues invade the muscle of the uterus.
Placenta percreta. The placental tissues extend all the way through the uterine muscle.
Although an uncommon event, uterine rupture can be life-threatening for the mother. Conditions that may increase the risk of uterine rupture include surgery to remove fibroid (benign) tumors and a prior cesarean scar. A prior scar on the uterus in the upper part of the fundus has a higher risk of uterine rupture compared with a horizontal scar in the lower uterine segment called a lower transverse incision. It can also occur before delivery and place the fetus at risk as well.
Why is postpartum hemorrhage a concern?
Excessive and rapid blood loss can cause a severe drop in the mother's blood pressure and may lead to shock and death if not treated.
What are the symptoms of postpartum hemorrhage?
The following are the most common symptoms of postpartum hemorrhage:
Decreased blood pressure
Increased heart rate
Decrease in the red blood cell count (hematocrit)
Swelling and pain in tissues in the vaginal and perineal area, if bleeding is due to a hematoma
The symptoms of postpartum hemorrhage may look like other conditions or medical problems. Always consult your doctor for a diagnosis.
How is postpartum hemorrhage diagnosed?
In addition to a complete medical history and physical exam, diagnosis is usually based on symptoms, with lab tests often helping with the diagnosis. Tests used to diagnose postpartum hemorrhage may include:
Estimation of blood loss (this may be done by counting the number of saturated pads, or by weighing of packs and sponges used to absorb blood; 1 milliliter of blood weighs approximately one gram)
Pulse rate and blood pressure measurement
Hematocrit (red blood cell count)
Clotting factors in the blood
Treatment for postpartum hemorrhage
The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as quickly as possible. Treatment for postpartum hemorrhage may include:
Medication (to stimulate uterine contractions)
Manual massage of the uterus (to stimulate contractions)
Removal of placental pieces that remain in the uterus
Examination of the uterus and other pelvic tissues, and examination of the vagina and vulva to look for areas that may need repair.
Bakri balloon or a Foley catheter to compress the bleeding inside the uterus. Packing the uterus with sponges and sterile materials may be used if a Bakri balloon or Foley catheter is not available.
Laparotomy. Surgery to open the abdomen to find the cause of bleeding.
Tying-off of bleeding blood vessels using uterine compression sutures. This is done during a laparotomy.
Hysterectomy. Surgical removal of the uterus; in most cases, this is a last resort.
Replacing lost blood and fluids is important in treating postpartum hemorrhage. Intravenous (IV) fluids, blood, and blood products may be given rapidly to prevent shock. The mother may also receive oxygen by mask.
Postpartum hemorrhage can be quite serious. However, quickly detecting and treating the cause of bleeding can often lead to a full recovery.