Postpartum hemorrhage is a medical term for bleeding after giving birth. As Dr. Samantha Do describes, postpartum hemorrhage is “one of the most common things that we think about for all patients and that we prepare for with all patients.” There are many ways different healthcare systems both in the U.S. and around the world classify postpartum hemorrhage. Some places consider any volume of blood loss over 500 mL severe, whereas others say over one liter, and others use stages or phases to monitor how severe the blood loss is.
Around the world, in places without robust healthcare systems and delivery centers, postpartum hemorrhage is the leading cause of maternal mortality. Fortunately in the U.S., this condition can be managed safely and there are many strategies to mitigate the risks associated with bleeding after delivery.
Any blood loss after giving birth should be given the proper context: during pregnancy, the body greatly increases blood volume in preparation for blood loss during birth. This means someone who has just given birth has a much higher tolerance for blood loss than someone who, for example, is bleeding as a result of a car accident. This is partly why postpartum hemorrhage is rarely dangerous.
The most common cause of postpartum hemorrhage is when the uterus doesn’t contract quickly enough or stays relaxed after delivery. Anatomically, there’s a large amount of blood entering the uterus throughout pregnancy, and the body has large, finger-sized arteries supplying the placenta to give the fetus the necessary nutrients and oxygen it needs to live.
After the placenta delivers, the way the body is designed to stop bleeding is by quickly contracting the entire uterus, not unlike stepping on a garden hose that’s on. However, uterine atony, when the uterus doesn’t clamp down, causes postpartum hemorrhage because those large blood vessels are still pumping out blood.
Dr. Samantha Do says that when monitoring postpartum hemorrhage, the focus is not only on the amount of blood lost, but how the patient is doing. “With every delivery, we’re monitoring how the uterus contracts, how much blood is lost and how the patient is feeling and doing with that blood loss. By quickly responding to a patient’s symptoms, vital sign changes, and blood loss, we can prevent excess bleeding entirely or prevent it from becoming dangerous.”
However, for some patients, like those who are severely anemic before delivery, postpartum hemorrhage can be a risk factor for other complications and impeded healing.
Many people after childbirth who have postpartum hemorrhage need little treatment after the initial management to control the bleeding; the situation can resolve rapidly once the uterus has finally shut those arteries. For uncontrolled or severe bleeding, which occurs very rarely, perhaps in 1% of births, mothers need a blood transfusion, which has very minimal risk.
For nearly all deliveries doctors will inject oxytocin intravenously immediately after birth to help induce the uterus to contract. Routine use of oxytocin following delivery has been proven to decrease blood loss. Another method of helping the uterus to contract is through uterine massage. While “massage” makes this sound like a soothing technique, Dr. Do clarifies: “It’s not the most comfortable thing, but it’s tolerable with an epidural and important to help the uterus contract.” If oxytocin and uterine massage alone do not resolve the bleeding, supplemental medications may be given to stop excess bleeding by causing the uterus to contract.
If conservative measures like uterine massage, medications and transfusing blood don’t work, patients will be taken to surgery to try to stop the bleeding. In very rare cases, sometimes the only way to stop the bleeding is by removing the uterus. Dr. Do explains, “That’s an exceptionally rare outcome to have a hysterectomy due to severe hemorrhage.
One of the routine things obstetricians do during pregnancy is check your blood counts. Your blood counts are monitored in the first trimester, third trimester and when you get admitted to the hospital for delivery. Having a high blood count is a good indicator of a successful, smooth delivery, because that means the patient has more capacity to tolerate blood loss. For patients with low blood counts, supplements may be provided to help achieve a higher blood count.
Dr. Nathan Fox explained having a good blood count prior to delivery this way: “When you show up on labor and delivery, think of it as if you’re going on a road trip. If you can start your road trip with a full tank of gas, it’s going to be better than if you start with a half tank of gas.”
The good news is that with modern testing, delivery, and treatment techniques, postpartum hemorrhage is usually nothing to worry about for the vast majority of pregnancies. Blood loss is a normal part of giving birth, and if too much blood seems to be coming out, our obstetricians have several methods of handling it.
Maternal Fetal Medicine Associates are proud to be the partners in health for so many mothers in New York City. If you’re pregnant or are planning to be pregnant, we’re here to help you get the resources, tests, and guidance you need during this life-changing time. Call us today or contact us online to get started.
Maternal Fetal Medicine blogs are intended for educational purposes only and do not replace certified professional care. Medical conditions vary and change frequently. Please ask your doctor any questions you may have regarding your condition to receive a proper diagnosis or risk analysis. Thank you!