Bleeding after the birth of a baby: Postpartum Hemorrhage

Definition

Postpartum hemorrhage is excessive bleeding after the birth of a baby. It is more common with cesarean]]> deliveries. In total postpartum hemorrhage only affects 4% of women who give birth. It can occur before or after you deliver the placenta. It can also occur hours or even days after the birth. Delayed postpartum hemorrhage can even occur up to 6 weeks after delivery. This is a potentially life-threatening condition that requires care from your doctor. Excessive and rapid blood loss can cause a severe drop in your blood pressure, which can lead to shock and death.

Postpartum Hemorrhage

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Causes

Some women are at greater risk than others. The following may lead to postpartum hemorrhage:

• Uterine atony (uncontrolled relaxation of the uterus)—most common
• Placental abruption]]>—the early detachment of the placenta from the uterus
• ]]>Placenta previa]]>—the placenta covers or is near the cervical opening
• Overdistended uterus—excessive enlargement of the uterus due to a large baby or an unusually large amount of amniotic fluid
• Multiple pregnancy—more than one placenta and overdistention of the uterus
• Pregnancy-induced high blood pressure
• Multiple previous births
• Prolonged labor
• Infection
• ]]>Obesity]]>
• Labor-inducing medications
• Medications to prevent preterm labor
• The use of forceps or vacuum during the delivery
• ]]>General anesthesia]]>
• Tear in the cervix or vaginal tissues
• Tear in a uterine blood vessel
• Bleeding into a concealed tissue area or space in the pelvis which develops into a hematoma, usually in the vulva or vaginal area
• Blood clotting disorders such as ]]>disseminated intravascular coagulation]]>
• Placenta accreta—the placenta is abnormally attached to the inside of the uterus (a rare condition but one that is more common if the placenta attached over a prior cesarean scar)
• Placenta increta—the placental tissues invade the muscle of the uterus
• Placenta percreta—the placental tissues go all the way into the uterine muscle and may break through (rupture)

Risk Factors

Some of the above causes are also risk factors for postpartum hemorrhage. Once the baby is delivered, the obstetrician will be watching for uterine contraction. Some birthing centers give all delivering mothers pitocin after the baby delivers. Pitocin]]> is a drug that prevents hemorrhage and induces uterine contractions.

The uterus continues to contract after the birth, working to return to its prepregnancy size. This activity helps deliver the placenta. Some birthing centers take a more natural approach and wait to see if there is any problem with bleeding. If the placenta is not delivered, your physician may prescribe uterus massage to help pass clots of blood. Talk to your obstetrician or midwife before the birth so you know what method to expect.

Symptoms

Some bleeding after the birth of a baby is normal. If you experience any of the following symptoms do not assume that you are experiencing postpartum hemorrhage. But contact your physician right away.

Symptoms:

• You are soaking more than one sanitary pad per hour for several hours.
• You have heavy, bright-red bleeding four or more days after the delivery.
• Your discharge has a foul smell.
• You are passing blood clots larger than a golf ball.
• This loss of blood is causing you to have heart palpitations, feel faint, lightheaded, and breathless.

Diagnosis

Your doctor usually diagnoses postpartum hemorrhage based on the symptoms.

Tests may include the following:

• Estimation of blood loss (this is done by counting or weighing the saturated pads)
• Pulse rate and blood pressure measurement
• Blood test to check for clotting factors and hematocrit (the % of red blood cells in the blood fluid)

Treatment

Talk with your doctor about the best treatment plan for you. Specific treatment will depend on your overall health, medical history, tolerance for medications and procedures, and your opinion or preference. The goal of treatment is to locate the cause and stop the excessive bleeding as fast as possible. Treatment options include the following:

• Medication—Drugs such as pitocin, methergine, and hemabate can stimulate uterine contractions.
• Manual massage of the uterus—This external pressing down on the pelvic area helps expel clots of blood from the uterus and helps the uterus contract.
• Removal of pieces of the placenta still in the uterus
• Packing the uterus with sterile materials to stop the bleeding
• Tying off bleeding blood vessels
• Laparotomy—This is open surgery on the abdomen to find the cause and stop the bleeding.
• Hysterectomy]]>—This is surgical removal of the uterus. This is a worst-case scenario for severe bleeding that is life-threatening.
• IV fluids, blood/blood products, oxygen—Your physician will replace lost blood and fluids, if necessary. These treatments are used to prevent shock.
• X-ray-guided uterine artery thromboembolism—a technique whereby a radiologist inserts a catheter into the femoral artery (in the groin) and injects substances which close off the bleeding artery

Prevention

To help reduce your chance of getting postpartum hemorrhage, take the following steps:

• Plan for and participate in regular, thorough prenatal care.
• Talk with your obstetrician or midwife about developing a birthing and complication plan.