Postpartum hemorrhage is excessive blood loss in the mother. It is called primary when it is within the first 24 hours after childbirth. Any excessive blood loss can put the mother at considerable risk. The blood loss is usually shortly after delivery.

Secondary postpartum hemorrhage occurs between 24 hours to six weeks after childbirth. Some blood loss is normal. However, postpartum hemorrhage is a potentially serious condition that often goes unrecognized. Talk with your doctor if you have any concerns about blood loss after giving birth.

Postpartum Hemorrhage

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The following are potential causes of postpartum hemorrhage:

  • Uterine atony (loss of tone of the muscles of the uterus)—most common cause
  • Rapid or prolonged labor
  • Overdistended uterus
  • Large baby
  • One or more previous pregnancies
  • Uterine infection
  • Medications that relax the uterus
  • Failure to deliver placenta
  • Birth trauma (lacerations of cervix and/or vagina)
  • Bleeding disorder
  • Anticoagulant medications
  • Uterine inversion (caused by failure of the placenta to detach from the uterus)
  • Retained products of conception after delivery of the placenta (eg, small pieces of placenta and/or fetal membranes)

Risk Factors

The following factors are thought to increase the risk of postpartum hemorrhage:

  • Prolonged active labor
  • Problems with the placenta (eg, retained placenta, placenta previa )
  • Multiple pregnancy
  • Pre-eclampsia (hypertension and presence of protein in the urine)
  • Obesity
  • Induced or augmented labor
  • Episiotomy —a procedure that involves cutting the perineum (the area of skin and muscle between the vagina and the anus)
  • Large fetus
  • History of previous postpartum hemorrhage
  • Ethnicity—Asian, Hispanic
  • Maternal blood disorders
  • Forceps or vacuum delivery
  • Cesarean section
  • First pregnancy
  • Stillbirth
  • Epidural anesthesia
  • Prolonged labor
  • Low-dose aspirin during pregnancy
  • Chorioamnionitis

Demonstration of Forceps and Vacuum Delivery

Vacuum and forceps delivery
© 2009 Nucleus Medical Media, Inc.

Signs and Symptoms

The most obvious sign is heavy vaginal bleeding during the first 24 hours after childbirth. If the bleeding is not obvious, other signs may include:

  • Decreased blood pressure
  • Increased heart rate
  • Decreased red blood cell count
  • Swelling and pain in the vaginal and perineal area


Your doctor will ask about your symptoms. A physical exam will be done. The doctor will check your perineum, vagina, cervix, and uterus for bleeding. Other tests may include:

  • Monitoring the number of saturated pads or sponges that absorb blood
  • Blood pressure measurement
  • Pulse measurement
  • Blood tests to detect blood levels and coagulation properties
  • Ultrasound —a test that uses sound waves to examine the body, in this situation the inside of the uterus for retained placental tissue
  • Angiography —x-ray exam of the blood vessels when they are filled with a contrast material (a substance that makes the blood vessels visible on an x-ray); usually only used if uterine artery embolization is considered for treatment


Talk with your doctor about the best plan for you. Treatment options include:

Fluids, Oxygen, and/or Resuscitation

You may need:

  • Fluids intravenously (through a vein in your arm)
  • Oxygen through a mask
  • In severe cases:

Bimanual Uterine Massage

A massage technique called bimanual uterine massage can control bleeding. A doctor or nurse will place one hand in your vagina to push on your uterus, while the other hand pushes down on your abdomen. This action will cause a relaxed uterus to contract, thus slowing bleeding.

Trauma Repair

Bleeding can be caused by a tear in your genital tract or other trauma. The tear will be sutured. In addition, tissue from a retained placenta may need to be removed.


Your doctor may prescribe medications to contract the uterus. Examples include:


In some cases, surgery may be needed, such as:

  • Uterine packing (sterile materials are placed inside the uterine cavity to compress the bleeding area)
  • Repair of arteries
  • Hysterectomy
  • Uterine curettage (scraping the lining of the uterus)
  • Repair of hematoma
  • Removal of retained placenta
  • Uterine artery embolization (non-invasive procedure to block the uterine artery)


These methods may reduce the risk of postpartum hemorrhage:

  • Avoiding episiotomy
  • Receiving continuous care from a midwife during labor
  • Being closely monitored during the third stage of labor
  • Identifying people who have the propensity to bleed (called a coagulation defect)