One of my nieces recently started bleeding the day after delivery and needed to have two units of blood transfused. She and the baby are fine. But this stimulated a lot of family talk about why bleeding occurs after delivery and how much is too much. I thought that reviewing the basics of postpartum (after the birth) hemorrhage (bleeding) (PPH) would be a good blog topic.
Background of PPH
Worldwide, PPH is still the leading cause of death for pregnant women. It has been a danger for a long time. The Taj Mahal in India is a memorial to an emperor’s wife who died from PPH in 1631. Death from PPH is now very rare in the United States, but PPH is not. It may occur in up to five percent of pregnancies.
PPH is a loss of more than about one pint of blood after a vaginal delivery or more than about one quart after a C-section. PPH that occurs within 24 hours of delivery is called primary PPH. PPH that occurs from 24 hours to six weeks after delivery is secondary PPH.
Causes of PPH
It’s easy to remember the causes if you know the “four Ts” of PPH:
- Tone refers to failure of the uterus to contact after delivery. This is called uterine atony. Normally the muscles of the uterus go into contraction to shut down bleeding. This feels like cramps. Failure of uterine tone is by far the most common cause of PPH.
- Tissue refers to a piece of the placenta that might stay in the uterus after delivery. This is more common if the placenta has grown abnormally or has an extra lobe.
- Trauma refers to a tear or a laceration that has occurred inside the vagina or uterus. This is more common with a C-section and any type of assisted delivery, such as the use of forceps.
- Thrombosis refers to any bleeding disorder that makes it hard for your body to form a blood clot. These conditions may be known or looked for if you have a history or family history of bleeding. A clotting disorder can also develop during pregnancy.
Are You at Risk?
You may be at increased risk for PPH if:
- You have a history of PPH.
- You are obese.
- You have high blood pressure.
- Your baby is over nine pounds.
- You are delivering twins or multiples.
- You are over age 40.
- You develop an infection in your uterus.
- You have a C-section, assisted delivery, or deliver under general anesthesia.
What Happens if You Have PPH?
Your OB caregivers will look for a cause and treat you according to the cause and how much blood you are losing. Primary PPH is usually diagnosed and treated before you leave the hospital. PPH that occurs at home requires a return to the hospital. Possible treatments may include:
- Intravenous (IV) fluids.
- Blood transfusion.
- Intravenous antibiotics.
- Massage of your uterus.
- Delivery or removal of any remaining placenta.
- Medications to stop bleeding or increase uterine contractions (tone).
- Temporary placement of an inflatable balloon inside your uterus.
- Surgery to control bleeding (if all else fails).
The best way to prevent postpartum hemorrhage is by getting good care during the third stage of labor. This is the stage between delivery of the baby and delivery of the placenta. Active management during the third stage includes anticipating risks and giving medication to prevent uterine atony.
How Much Bleeding Is Too Much Bleeding?
You can have PPH without much blood showing because it may be pooling inside your uterus. Hospital caregivers will look for other signs and symptoms of blood like dropping blood pressure, rapid heartbeat, cold clammy skin, pallor (pale skin), weakness, and dizziness. The common term for these signs and symptoms is shock.
If you have secondary PPH at home, you need to know when to call your doctor. It is normal to have discharge mixed with blood – called lochia – during the first 4 days after delivery. You need to call your doctor if:4
- You have any bright red bleeding after four days.
- You soak through more than one pad per hour.
- You pass a clot the size of a golf ball or larger.
- You have signs of blood loss such as dizziness, cold and clammy skin, rapid pulse, or dizziness.
- You have belly pain, fever, chills, or foul smelling vaginal discharge.
Talk to your OB provider about possible risks for PPH. PPH is dangerous but, in this country, rarely life-threatening. Ninety-nine percent of cases can be managed without major surgery.