Postpartum Hemorrhage
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Postpartum Hemorrhage

(Obstetric Hemorrhage)

En Español (Spanish Version)

Definition

Postpartum hemorrhage is excessive blood loss in the mother within the first 24 hours after childbirth. Normal blood loss has been defined as up to 500 milliliters. The measures for a postpartum hemorrhage has been set at a total loss of greater than 1000 milliliters of blood within the first 24 hours after childbirth. This definition applies to both vaginal deliveries and Cesarean sections.

Late 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. Talk with your doctor if you have any concerns about blood loss after giving birth.

Causes

The following are potential causes of postpartum hemorrhage:

  • Uterine atony, loss of tone of the muscles of the uterus, most common cause
  • Rapid or prolonged labor
  • Overdistended uterus
  • Large baby
  • One or more previous pregnancies
  • Uterine infection
  • Medications that relax the uterus
  • Failure to deliver placenta
  • Birth trauma (lacerations of cervix and/or vagina)
  • Bleeding disorder
  • Anticoagulant medications
  • Uterine inversion (caused by failure of the placenta to detach from the uterus)
  • Retained products of conception after delivery of the placenta (eg, small pieces of placenta and/or fetal membranes)

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

The following factors are thought to increase the risk of postpartum hemorrhage:

  • Prolonged active labor
  • Problems with the placenta (eg, retained placenta, placenta previa)
  • Multiple pregnancy
  • Preeclampsia (hypertension and presence of blood in the urine)
  • Obesity
  • Induced labor
  • Episiotomy—a procedure that involves cutting the perineum (the area of skin and muscle between the vagina and the anus)
  • Large fetus
  • History of postpartum hemorrhage
  • Asian or Hispanic ethnicity
  • Maternal blood disorders
  • Forceps or vacuum delivery
  • Cesarean section
  • Never having carried a pregnancy (previously)
  • Stillbirth
  • Epidural anesthesia
  • Prolonged labor
  • Low-dose aspirin during pregnancy

Demonstration of Forceps and Vacuum Delivery

Vacuum and forceps delivery

© 2008 Nucleus Medical Art, Inc.

Signs and Symptoms

The most obvious sign of postpartum hemorrhage is heavy vaginal bleeding during the first 24 hours after childbirth. If the bleeding is not obvious, other suggestive signs may include:

  • Decreased blood pressure
  • Increased heart rate
  • Decreased red blood cell count
  • Swelling and pain in the vaginal and perineal area

Diagnosis

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

  • Monitoring the number of saturated pads or sponges that absorb blood
  • Blood pressure measurement
  • Pulse measurement
  • Blood tests
  • Ultrasound—a test that uses sound waves to examine the body
  • Angiography—x-ray exam of the blood vessels when they are filled with a contrast material (a substance that makes the blood vessels visible on an x-ray)

Treatment

Talk with your doctor about the best treatment plan for you. Treatment options include:

Fluids, Oxygen, and/or Resuscitation

Depending on the rate of your bleeding and your symptoms, you may need fluids through an intravenous line and/or oxygen through a mask placed over your nose and mouth. If your bleeding is severe, you may be taken to the intensive care unit for resuscitation. In some cases, blood transfusion may be required.

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 preventing brisk bleeding.

Trauma Repair

If your bleeding is caused by a tear in your genital tract or other trauma, the tear will be sutured and/or trauma will be corrected (eg, replace inverted uterus). In addition, tissue from a retained placenta may need to be manually removed.

Medications

Oxytocin (Pitocin), carboprost (Hemabate), misoprostol (Cytotec), methylergonovine (Methergine), and/or ergometrine (Ergonovine) can be given to treat postpartum hemorrhage.

Surgery

In some cases of postpartum hemorrhage, surgery may be required. Surgery may involve uterine packing (applying sterile materials inside the uterine cavity to compress the bleeding area), repair of arteries, hysterectomy, uterine curettage (scraping the lining of the uterus), repair of hematoma (coagulation of blood), and/or removal of retained placenta.

Insertion of a catheter into the uterine artery under x-ray guidance, followed by embolization (blockage) of the uterine artery is a possible alternative to surgery.

Prevention

Methods that have been proposed to reduce the risk of postpartum hemorrhage include:

  • Avoiding episiotomy
  • Receiving continuous care from a midwife during labor
  • Active management of third stage of labor (eg, use of uterotonic drugs such as oxytocin, controlled delivery of placenta, uterine massage)
  • Identification of patients with a coagulation defect (propensity to bleed)

RESOURCES:

American College of Obstetricians and Gynecologists
http://www.acog.org

American Pregnancy Association
http://www.americanpregnancy.org

CANADIAN RESOURCES:

Canadian Association of Pregnancy Support Services
http://www.capss.com

The Society of Obstetricians and Gynaecologists of Canada
http://sogc.medical.org/

References:

American College of Obstetricians and Gynecologists. Postpartum Hemorrhage. October 2006. ACOG Practice Bulletin 76.

Postpartum hemorrhage. DynaMed website. Available at: http://dynamed102.ebscohost.com/Detail.aspx?id=114247#bimanual_uterine_massage. Accessed June 25, 2007.

Postpartum hemorrhage. University of Virginia Health System website. Available at: http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnant/postpart.cfm. Accessed June 25, 2007.



Last reviewed April 2008 by Ganson Purcell Jr., MD, FACOG, FACPE

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

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