Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours after childbirth. Diagnosis is clinical. Treatment depends on etiology of the hemorrhage.
Etiology of Postpartum Hemorrhage
The most common cause of postpartum hemorrhage is
Uterine atony
Risk factors for uterine atony include
Uterine overdistention (caused by multifetal pregnancy, polyhydramnios, fetal anomaly, or an abnormally large fetus)
Prolonged labor or dysfunctional labor
Grand multiparity (delivery of ≥ 5 viable fetuses)
Relaxant anesthetics
Rapid labor
Intra-amniotic infection (chorioamnionitis)
Other causes of postpartum hemorrhage include
Lacerations of the genital tract
Extension of an episiotomy
Retained placental tissues
Hematoma
Intra-amniotic infection
Subinvolution (incomplete involution) of the placental site (which usually occurs early but may occur as late as 1 month after delivery)
Uterine fibroids may contribute to postpartum hemorrhage. A history of postpartum hemorrhage may indicate increased risk.
Diagnosis of Postpartum Hemorrhage
Clinical estimate of blood loss
Monitoring vital signs
There are various assessment tools (eg, checklists) to help obstetric practitioners and health care facilities develop ways to rapidly recognize and manage postpartum hemorrhage (1, 2). These tools are widely available and can be adjusted to suit the needs of the specific patient population.
Diagnosis references
1. California Maternal Quality Care Collaborative Hemorrhage Task Force: OB hemorrhage toolkit V 2.0. Accessed November 2, 2023
2. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics: Practice Bulletin No. 183: Postpartum hemorrhage. Obstet Gynecol 130:e168–186, 2017. doi:10.1097/AOG.0000000000002351
Treatment of Postpartum Hemorrhage
Fluid resuscitation and sometimes transfusion
Uterine massage
Removal of retained placental tissue
Repair of genital tract lacerations
Sometimes surgical procedures
Intravascular volume is replenished with 0.9% saline up to 2 L IV; blood transfusion is used if this volume of saline is inadequate.
Procedure by Kate Barrett, MD and Will Stone, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; Barton Staat, MD, Uniformed Services University; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; Assisted by Elizabeth N Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.
Procedure by Kate Leonard, MD, and Will Stone, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University. Assisted by Elizabeth N. Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.
Procedure by Kate Barrett, MD and Will Stone, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; Barton Staat, MD, Uniformed Services University; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University and Walter Reed National Military Medical Center. Assisted by Elizabeth N Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.
Procedure by Kate Barrett, MD and Will Stone, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; Barton Staat, MD, Uniformed Services University; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; Assisted by Elizabeth N Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.
Procedure by Kate Leonard, MD, and Will Stone, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University. Assisted by Elizabeth N. Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.
Procedure by Kate Barrett, MD and Will Stone, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; Barton Staat, MD, Uniformed Services University; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University and Walter Reed National Military Medical Center. Assisted by Elizabeth N Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.
In addition, the uterus is explored for lacerations and retained placental tissues. The cervix and vagina are also examined; lacerations are repaired. Bladder drainage via catheter can sometimes reduce uterine atony.
Uterine packing or placement of a Bakri balloon can sometimes provide tamponade. This silicone balloon can hold up to 500 mL and withstand internal and external pressures of up to 300 mm Hg. If hemostasis cannot be achieved, surgical placement of a B-Lynch suture (a suture used to compress the lower uterine segment via multiple insertions), hypogastric artery ligation, or hysterectomy may be required. Uterine rupture requires surgical repair.
An intrauterine vacuum-induced hemorrhage-control device may be used. It applies low-level suction to induce uterine contractions, causing the uterus to collapse on itself; as a result, blood vessels in the myometrium constrict and hemorrhage is rapidly stopped (1). The device consists of an intrauterine loop, an expandable seal that is filled with sterile fluid and blocks the cervix to maintain the vacuum, and a vacuum connector attached to a tube that connects with a vacuum source. Suction is applied for 1 hour after bleeding is controlled.
Blood products are transfused as necessary, depending on the degree of blood loss and clinical evidence of shock. Massive transfusion of packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio can be considered after consultation with the blood bank (2).
Treatment reference
1. D’Alton ME, Rood KM, Smid M C, et al: Intrauterine vacuum-induced hemorrhage-control device for rapid treatment of postpartum hemorrhage. Obstet Gynecol 136 (5):1–10, 2020. doi: 10.1097/AOG.0000000000004138
Prevention of Postpartum Hemorrhage
Predisposing conditions (eg, uterine fibroids, polyhydramnios, multifetal pregnancy, a maternal bleeding disorder, history of puerperal hemorrhage or postpartum hemorrhage) are identified antepartum and, when possible, corrected.
If women have an unusual blood type, blood available for transfusion appropriate for that blood type is made available ahead of time. Careful, unhurried delivery with a minimum of intervention is always wise.
After the placenta is delivered, it is thoroughly examined for completeness; if it is incomplete, the uterus is manually explored and retained fragments are removed. Rarely, curettage is required.
Uterine contraction and amount of vaginal bleeding must be observed for 1 hour after completion of the third stage of labor.
Key Points
Before delivery, assess risk of postpartum hemorrhage, including identification of antenatal risk factors (eg, bleeding disorders, multifetal pregnancy, polyhydramnios, an abnormally large fetus, grand multiparity).
Postpartum hemorrhage assessment tools are widely available and can be adjusted for the specific patient population.
Replenish intravascular volume, repair genital lacerations, and remove retained placental tissues.
If hemorrhage persists, consider use of an intrauterine vacuum device, intrauterine balloon tamponade, packing, surgical procedures, and transfusion of blood products.
For women at risk, deliver slowly and without unnecessary interventions.
