Postpartum hemorrhage is defined as a loss of blood in the postpartum period of more than 500 mL. The average, spontaneous vaginal birth will typically have a 500 mL blood loss. In cesarean births, the average blood loss rises to between 800 and 1000 mL. The risk of hemorrhage is highest in the first 24 hours after the birth, which is known as primary postpartum hemorrhage. Secondary hemorrhage is one that occurs after the first 24 hours of birth.
Risk Factors
Hemorrhage can occur in people with or without any risk factors. However, people who are at greater risk include those with multiple gestations (twins, etc.), a very large singleton baby, and people who have had several prior pregnancies. Pregnancies involving medical conditions such as polyhydramnios (excess amniotic fluid), placenta previa, or placental abruption as well as medications used during labor including Pitocin, general anesthesia, and magnesium sulfate can also increase the risk of postpartum hemorrhaging. If you have any of these risk factors, your doctor will likely take additional precautions to prevent hemorrhage and observe you more closely in the 24 to 48 hours after giving birth.
Causes
In the majority of cases, postpartum hemorrhage is due to uterine atony, meaning that the uterus is not contracting enough to control the bleeding at the placental site. Other causes include retained placental fragments (possibly including a placenta accreta), a trauma of some form (like a cervical laceration, uterine inversion, or even uterine rupture), and clotting disorders. If hemorrhage occurs, steps to treat the bleeding include uterine massage, placing the person’s feet above her heart, giving the person oxygen, and certain medications. In rare but extreme cases, surgery may be needed, including a hysterectomy (removal of the uterus).
Prevention
All birthing people receive care to help prevent hemorrhage after the birth of their baby. Immediately following the birth of the baby, the medical team watches for signs of placental separation to indicate the placenta is ready to be delivered. Some hospitals and birth centers use a routine Pitocin injection to help ensure that the placenta comes quickly and completely, while others choose to wait and see if there is a bleeding problem. Other medications used to prevent postpartum hemorrhage include misoprostol, ergometrine, carbetocin, or a combination of those drugs. The American Academy of Pediatrics (AAP) recommends breastfeeding as soon as possible after birth. This prompts the release of oxytocin (nature’s Pitocin) to help contract the uterus and expel the placenta. Massaging the uterus is also done to help expel clots of blood and check uterine tone to ensure that it is clamping down to prevent excessive bleeding. The poor tone of the uterus at this point causes 70% of postpartum hemorrhage cases. If it is too painful, medications can also be used. This will be done with decreasing frequency after birth, as your bleeding slows. After the placenta is delivered, ensuring your bladder is empty can also avoid hemorrhage. Women who have not used regional anesthesia can usually use the restroom themselves within the hour after birth, while those who had an epidural may need to use a bedpan or may already have a catheter in place.
A Word From Verywell
While postpartum hemorrhage occurs in less than 5% of births, it accounts for one-quarter of maternal deaths worldwide. During your prenatal check-ups, talk to your midwife or obstetrician about your personal risk factors and prevention strategy for postpartum hemorrhage, and understand the protocols in place to keep you safe.
