Excessive bleeding from the uterus refers to loss of more than 2 pints of blood or symptoms of significant blood loss that occur within 24 hours after childbirth.
After the baby is delivered, excessive bleeding from the uterus is a major concern.
Ordinarily, a woman loses about 1 pint of blood during and after vaginal delivery. Blood is lost because some blood vessels are opened when the placenta detaches from the uterus. The contractions of the uterus help close these vessels until the vessels can heal. Typically, cesarean delivery results in about twice the blood loss as vaginal delivery, partly because delivery requires an incision in the uterus, and a lot of blood is pumped to the uterus during pregnancy.
Blood loss is considered excessive if one of the following occurs within 24 hours of delivery:
More than 2 pints of blood are lost.
A woman has symptoms of significant blood loss, such as low blood pressure, a rapid heart rate, dizziness, light-headedness, fatigue, and weakness.
Excessive blood loss usually occurs soon after delivery but may occur as late as 1 month afterward.
Causes of Postpartum Hemorrhage
The most common cause of excessive bleeding at delivery is
A uterus that does not start contracting after delivery but instead remains loose and stretched out (a condition called uterine atony)
When the uterus does not start contracting after delivery, the blood vessels that were opened when the placenta detached continue to bleed.
Contractions may be impaired when
The uterus has been stretched too much—for example, by too much amniotic fluid in the uterus, by several fetuses (multiple births), or by a very large fetus
Labor was prolonged, abnormal, or rapid
A woman has given birth to 5 or more babies
A muscle-relaxing anesthetic was used during labor and delivery
The membranes around the fetus are infected (called intra-amniotic infection)
Excessive bleeding can also result when
The vagina or cervix is torn during delivery
The cut made during an episiotomy extends too far
A woman has a bleeding disorder that interferes with clotting
Intra-amniotic infection leads to infection of the uterus (called endometritis)
A piece of the placenta remains inside the uterus after delivery
The uterus ruptures or is turned inside out (inverted), both of which are rare)
Excessive bleeding after one delivery may increase the risk of excessive bleeding after subsequent deliveries.
Fibroids in the uterus may also increase the risk.
Diagnosis of Postpartum Hemorrhage
A doctor's estimate of blood loss
Monitoring vital signs
The diagnosis of postpartum hemorrhage is based on close observation of the amount of bleeding.
Monitoring a woman's vital signs, such as blood pressure and heart rate, can help doctors determine whether blood loss is excessive. A drop in blood pressure or a rapid heart rate may indicate excessive bleeding.
Treatment of Postpartum Hemorrhage
Massage of the uterus
Medications to help the uterus contract
Fluids given by vein (intravenously)
Sometimes a blood transfusion
Removal of any remaining fragments of the placenta
Sometimes a procedure to compress the arteries to the uterus
A woman may need a blood transfusion.
Doctors look for the cause of excessive bleeding. The uterus may be examined to see whether any fragments of the placenta remain. Any fragments that remain in the uterus are removed by hand. Rarely, dilation and curettage is needed to remove these fragments. In this procedure, a small, sharp instrument (curet) is passed through the cervix (which is usually still open from the delivery). The curet is used to remove the retained fragments. This procedure requires an anesthetic. The cervix and vagina are examined for tears.
If the uterus cannot be stimulated to contract and bleeding continues, the arteries supplying blood to the uterus may have to be compressed to stop blood flow. Procedures that may be used include the following:
A balloon may be inserted into the uterus and inflated.
Packing may be inserted into the uterus.
A doctor may place stitches (sutures) around the bottom of the uterus—a procedure that requires abdominal surgery.
A device that applies gentle suction to the uterus and thus helps the uterus contract may be placed in the uterus.
The procedures usually do not cause infertility, abnormalities in menstruation, or other lasting problems.
Sometimes the arteries supplying blood to the uterus must be blocked surgically or by inserting material through catheters into the arteries.
Removal of the uterus (hysterectomy) is rarely necessary to stop the bleeding.
Prevention of Postpartum Hemorrhage
Before a woman goes into labor, doctors take steps to prevent or prepare for excessive bleeding after delivery. For example, they determine whether the woman has any conditions that increase the risk of bleeding (such as too much amniotic fluid or a bleeding disorder). These conditions are treated if possible.
If a woman has an unusual blood type, blood of that type is on hand in case she needs a blood transfusion.
After delivery of the placenta, a woman is monitored for at least 1 hour to make sure that the uterus has contracted and to assess bleeding.
