Postpartum hemorrhage

How does this happen?

After the placenta separates, the site where it was attached is an open wound with large blood vessels running to it. The body closes those vessels in one main way: the muscle of the uterus contracts down hard, squeezing them shut. Clotting is secondary.

That is why a uterus that does not contract is the most common cause of heavy bleeding, and why the first treatments are all aimed at making it contract. ¹

The causes are traditionally grouped as four.

• Tone. The uterus does not contract. More likely after a long labor, a very fast labor, a large baby, twins, a lot of fluid, prolonged oxytocin use, infection, or many previous births.
• Tissue. Part of the placenta is retained, so the uterus cannot close down properly. Placenta accreta spectrum, where the placenta grows into the wall, is a specific and serious version of this. ³
• Trauma. Tears of the cervix, vagina or perineum, or a uterine rupture.
• Thrombin. A clotting problem, either pre-existing or developing during the bleeding itself.

There is a fifth factor that is not on the list and matters: recognition. Blood loss is routinely underestimated by eye, which is why quantitative measurement is recommended rather than estimation. ¹

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• Uterine atony with no identified risk factor, which is common and unpredictable.
• Placental abruption, which can happen without warning. ⁴
• Placenta accreta spectrum, where the placenta has grown into the uterine wall, sometimes not diagnosed before birth. ³
• A large baby, twins, or a lot of amniotic fluid, all of which overstretch the uterus. ⁵
• A pre-existing clotting condition.
• Infection. ⁶
• A precipitous labor.

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Risk factors not assessed, where guidance recommends risk assessment on admission and reassessment during labor. ¹
• Blood loss estimated by eye rather than measured, so the scale of bleeding was recognized late. ¹
• No hemorrhage protocol followed, or the escalation stages not used.
• Uterotonic medicines not given promptly or the sequence not escalated. ¹
• Retained placental tissue not identified or not removed.
• A tear not found, where examination of the cervix and vagina is part of the assessment. ⁷
• Blood products not available or not given in time.
• oxytocin used in a way that contributed to atony, where guidance addresses its use. ⁸
• Anemia in pregnancy not treated, so the person started labor with less reserve. ²

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record. Hemorrhage records are unusually detailed, with timed medication entries and running blood loss totals.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• Bleeding that soaks through pads quickly, or a steady trickle that does not stop.
• Large clots.
• A uterus that feels soft rather than firm.
• Feeling faint, dizzy, breathless, cold, clammy or unusually anxious. That specific sense of something being badly wrong is a recognized symptom of blood loss and it should be said out loud.
• A rising heart rate and a falling blood pressure, though blood pressure can stay normal until a great deal of blood has been lost.

The first week

• Continued heavy bleeding, or bleeding that restarts.
• Passing large clots.
• Fever with heavy bleeding, which suggests infection.
• Extreme fatigue, breathlessness on climbing stairs, and dizziness from anemia.
• Delayed hemorrhage, which can occur days after birth, often from retained tissue or infection. ¹

Around 3 months

• Fatigue that is out of proportion to newborn tiredness, often from anemia that has not been treated.
• Difficulty with milk supply, which can follow severe blood loss.
• Absent periods and other effects if the pituitary gland was affected by severe blood loss, which is uncommon but recognized.
• Post-traumatic stress symptoms, which are common after a frightening hemorrhage. ⁹

Around 6 months

• Ongoing anemia if it was not treated.
• Emotional effects, including intrusive memories and fear of a future pregnancy.

Around 12 months

• Most physical recovery is complete.
• Fertility questions after any procedure that affected the uterus.

Toddler years

• Not applicable to the mother's recovery timeline; effects on the baby, if any, follow any period of reduced oxygen during the event.

School age

• Not applicable.

How is it diagnosed?

Diagnosis is clinical and it depends on measuring rather than estimating.

Quantitative blood loss measurement, using weighed pads and calibrated drapes rather than visual estimation, which is unreliable. ¹

Examination of the uterus, to feel whether it is contracted.

Examination of the cervix and vagina, to find tears.

Examination of the placenta, to check it is complete.

Blood tests, including blood count and clotting studies, repeated as bleeding continues.

Ultrasound, to look for retained tissue.

Finding the cause matters, because the treatment differs. A soft uterus needs medicines that make it contract. A tear needs repair. Retained tissue needs removal. A clotting problem needs blood products. ¹

Afterward, request the records. Ask for the quantified blood loss, the medicines given with times, the blood products given, and any procedures. ¹⁰

What is the treatment?

Treatment follows a sequence, and hospitals are expected to have it written down and rehearsed. ¹

Uterine massage and emptying the bladder.

Medicines that make the uterus contract, given in sequence: oxytocin first, then others such as methylergonovine, carboprost or misoprostol, chosen according to the person's other conditions.

Tranexamic acid, which reduces bleeding and is recommended early rather than late. ¹

Finding and fixing the cause: repairing tears, removing retained tissue.

Devices and procedures: a balloon placed inside the uterus to apply pressure, or a vacuum-induced device.

Blood products, including a massive transfusion protocol where bleeding is severe.

Surgery, including compression sutures, tying off blood vessels, and in the last resort hysterectomy, which stops the bleeding and ends fertility.

Interventional radiology, where available, to block the arteries supplying the uterus.

Afterward: iron treatment, sometimes intravenous, because oral iron alone often does not correct significant anemia quickly enough for someone caring for a newborn. Ask about it directly. ²

What is the long-term outlook?

Most people who have a postpartum hemorrhage recover fully. ¹

Recovery from the blood loss itself takes weeks to months, and anemia is frequently under-treated. Profound fatigue in the months after a hemorrhage is usually anemia and not simply new parenthood.

Where a hysterectomy was needed, fertility ends, and that is a significant loss that deserves proper support and not only a medical follow-up.

Post-traumatic stress after a severe hemorrhage is common. Many people describe vivid, intrusive memories and fear about any future pregnancy. This is treatable. ^{9 11}

For a future pregnancy, a history of postpartum hemorrhage raises the risk of another, which is why it belongs at the front of the notes and in the birth plan. ¹

What does daily life look like?

The first weeks are often much harder than expected. Anemia makes stairs hard, makes concentration hard, and makes everything about a newborn harder.

Ask for a blood count and ask about intravenous iron rather than assuming tiredness is normal. ²

Milk supply can be affected by severe blood loss, and lactation support is worth asking for early.

Ask for a debrief appointment with the team who cared for you. Many people find that going through what happened, in order, with the record in front of them, does more for the intrusive memories than anything else.

What does care cost over a lifetime?

No agency publishes a lifetime cost estimate for postpartum hemorrhage, and this site does not invent one.

The immediate costs are the hospital stay, blood products, and any procedures. Ongoing costs are usually limited to treating anemia and any mental health support.

See paying for care.

What can you do this week?

1. Request the delivery record and the quantified blood loss, using the records request builder.
2. Ask what caused it: tone, tissue, trauma or clotting.
3. Ask for a blood count and ask specifically about intravenous iron if you are exhausted.
4. Ask what procedures were done and what that means for future pregnancies.
5. Ask for a debrief appointment with the team who were there.
6. Tell someone if you are having intrusive memories or panic. It is common and treatable. ¹²
7. Ask what should be in your notes for a future pregnancy.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the obstetrician

• What was my measured blood loss?
• What caused the bleeding?
• What medicines and blood products did I receive, and when?
• What procedures were done, and what do they mean for future pregnancies?
• What should I tell a future maternity team?

For your own recovery

• What is my hemoglobin now, and what should it be?
• Should I have intravenous iron rather than tablets?
• Why am I still this tired, and what would you check?
• Who can I talk to about how frightening this was?

You can also build a printable list with the question generator.