Bleeding after giving birth

A postpartum haemorrhage, or “PPH”, is when a mother bleeds heavily after childbirth, losing over 500mls of blood. A heavy bleed within the first 24 hours of delivery is called a primary PPH. After this, any bleeding up until 12 weeks after the birth is called a secondary PPH. Maternity professionals also classify these bleeds into minor, when 500-1000mls of blood is lost, and major, when over 1000mls is lost. Losing over 2000mls of blood is called a massive PPH. Estimating blood lost into pads, swabs or bedpans is difficult and rarely accurate; many hospitals now try to weigh any blood lost during a PPH to make the estimation more precise.

Although severe PPH is uncommon, any heavy bleed after birth can be a scary and potentially dangerous event. It is very hard to work out how often PPHs occur in the UK due to the difficulty in estimating blood loss accurately; rates of 5-15% have been described, although some studies suggest rates as high as 33% for minor PPH. A small number of women still die each year due to PPHs, but thankfully the vast majority are dealt with quickly by midwives and doctors who have many different techniques they can use to keep you safe if this happens. Although hospitals will try to identify women at higher risk of PPH, often the cause could not have been predicted. This is another reason prompt recognition and management are essential.

What can cause PPH?

After birth, the muscle fibres of the womb contract rapidly. They squeeze the blood vessels between them as they do so, sealing them off and stopping the bleeding. One common cause of PPH is when the uterus becomes floppy and soft after delivery; it then does not clamp down to stop the bleeding as it usually would. This is more likely if you’ve had a long labour, received an oxytocin infusion, are obese or have had a PPH before. Large fibroids can also impair the womb’s ability to contract quickly.

Problems with the placenta can lead to a PPH. If the placenta is abnormally stuck to the womb, there are fragments of it left inside or if it simply won’t detach (retained placenta), it will stop the uterus clamping down.

If your womb was very big to start with, such as in multiple pregnancies or if you had high levels of fluid surrounding the baby (polyhydramnios), it will take longer to contract after delivery and more blood may be lost in the meantime. Bleeding can occur from vaginal tears and episiotomies but equally at caesarean section the large blood vessels supplying the uterus can bleed when it is cut to deliver the baby.

There are other rarer causes of PPH too, such as rupture of a caesarean scar in labour. Some of these are issues with the ability of blood to clot; either because of known problems with a mother’s blood or because of medication she is taking. Pre-eclampsia, placental abruption and infection are all also risk factors.

Can PPH be prevented?

Most of the risk factors mentioned above can’t be easily changed. If any of them apply to you, this is likely to have been picked up before labour and delivery, and preparations put in place. These include:

• Sending a blood sample (“group and save”) to the laboratory in case you need a transfusion.
• Recommending that a cannula (drip) be placed in your hand and arm prior to delivery.
• Having an active third stage of labour.

If you wish to have a homebirth or deliver in a birthing centre but are at a higher risk of PPH, you should have a discussion with both the doctors and midwives at your local maternity unit to discuss the risks and benefits of each option. Women naturally become slightly anaemic (low in iron) during pregnancy, which slows the recovery from a PPH; many people are recommended to take iron supplements to improve their haemoglobin levels before delivery. For very anaemic women, iron infusions through a drip are sometimes used.

What happens during a PPH?

This depends on how quickly the blood loss occurs. For example, a woman may lose 300mls of blood at the time of delivery, but go on to pass further blood or blood clots twice over the next hour or so, estimated to be 150mls each. Technically this is a PPH, but it may not be recognised as such by staff and the woman is likely to suffer no adverse effects and need no treatment. However, small repeated bleeds can add up and staff need to be vigilant.

When the blood loss is immediate and rapid, whoever attended to you during delivery will request immediate assistance, which is often done by pulling an emergency buzzer if you delivered in hospital. Lots of different members of staff will arrive. If you are at home or at a birth centre, your midwife will wish to transfer you quickly to an obstetric unit.

The main aim when treating a PPH is to stop the bleeding and therefore the actions taken will depend on the cause. Each step should be explained and consent requested, but this is likely to happen quickly as speed is essential to successful treatment during this emergency.

A midwife or doctor will ask to examine you and may need to perform a manoeuvre called bimanual compression. This involves pushing firmly on the lower belly so that the uterus is compressed, and using a hand fully inside the vagina to assist this compression. This can be thought of as the same pressure you might apply to any injury that was bleeding heavily.

At the same time, another member of the team will insert one or even two drips into your hand or arm and take small samples for blood tests if this hasn’t happened already. They will then start an infusion of fluid running rapidly through the drip to quickly replace the blood you have lost.

Most women in the UK have active third stages of labour and have already had an injection of one or two drugs at the time of delivery to reduce bleeding. If you chose not to have this, the team will ask your permission to give it to you. As well as an injection, a slower infusion of oxytocin may also be given.

After these immediate actions, your doctor and midwife will reassess the bleeding and work out what may have caused it so they can tailor further treatment accordingly. Often the treatment above is successful and nothing more is required, in which case you will simply be monitored more closely for a few hours.

Further treatment may involve more drugs to make the uterus contract (called ergometrine, carboprost or misoprostol), and a drug to help blood to clot (tranexamic acid). They will wish to perform a vaginal examination to see if the bleeding is coming from a cut or tear. There may be blood clots sitting within the cervix preventing it from closing effectively, and these can be removed by the doctor during an examination. If your placenta is still inside the womb, they will attempt to remove it by steadily pulling on the umbilical cord.

If the tear is severe, or the placenta will not deliver easily, or if the bleeding continues despite the above treatment, your doctor may wish to transfer you to the operating theatre. An anaesthetist will come to discuss the anaesthetic, and the planned procedure will be discussed with you, and confirmed with a signed consent form, including whether or not you would accept a blood transfusion. A regional anaesthetic (spinal injection or an epidural top-up) is usually sufficient but in severe cases a general anaesthetic may be recommended.

The vast majority of PPHs respond to treatment in the room, or with basic procedures such as manual removal of placenta or repairing perineal trauma. Although beyond the scope of this article, there are advanced techniques that can be performed in rare cases of severe ongoing bleeding. Senior doctors would become involved at this point, as well as a haematologist who will advise on what blood products you will need as a transfusion.

Will I need a blood transfusion?

Having a PPH does not mean you will need a blood transfusion. Pregnancy prepares the body for potential blood loss by increasing how much blood is in the body by an incredible 40%, which means although excessive blood loss is a concern, women’s bodies cope very well naturally with this complication.

With blood losses of around 1000mls or below, a blood transfusion is unlikely to be recommended immediately. A blood count (FBC) will be taken 6 hours after your delivery, and the results of this combined with your vital signs and how you are feeling will be used to decide whether or not to recommend transfusion.

If you are estimated to have lost 2000mls or more, it is likely that you will need a transfusion, and this is likely to be recommended without waiting for further tests. The transfusion may even be started whilst a procedure is still going on, providing you have given your consent for this to happen.

What happens after a PPH?

For smaller PPHs, especially if you did not need a blood transfusion or a procedure in the operating theatre, there may be no significant impact on your postnatal period. You will be recommended to await the results of a blood test (which can be 6 hours after the delivery or sometimes the following day) to see how your body has adapted to the blood loss. Depending on the result, you may be given some iron supplements to take home.

For large PPHs, and if you needed a blood transfusion or procedure under anaesthetic, you will need closer monitoring for the first 12-24 hours to ensure that your body is coping with the blood loss. Your heart rate, blood pressure, oxygen saturation and temperature will be checked regularly, and you will be recommended to stay in hospital at least overnight as there is sometimes a delay in how the blood loss affects your system. You should be given an opportunity to talk about the event and ask any questions, as this can be quite traumatic for you and your birthing partner too. You should be given iron supplements to take home.

When at home, your body will recover and create more blood, but this can take 2-4 weeks. You may feel more tired and need more support than women who have not experienced a PPH. Your lochia should not be any different, lasting 2-6 weeks, and turning from a red to a brownish colour. If you experience fresh red or heavy bleeding or blood clots bigger than 50p size, you should speak to your midwife.

If you have further pregnancies, it should be noted in your record that you experienced a PPH and approximately how much blood you lost, as well as the reason. Your maternity team can then help you prepare for a safe delivery.

Main Points

• A postpartum haemorrhage, or “PPH”, is when a mother bleeds heavily after childbirth.
• PPH can be very dangerous, and a small number of cases each year are fatal, but thankfully the vast majority are dealt with quickly by midwives and doctors.
• Heavy bleeding within 24 hours of delivery is called a primary PPH, while bleeding after this and up until 12 weeks post-birth is referred to as secondary PPH. Bleeds can also be classified as minor, when 500-1000mls is lost, major, which is over 1000mls, and massive PPH, when over 2000mls of blood is lost.
• A common cause of PPH is when the womb, which normally contracts rapidly after birth to prevent bleeding, becomes soft and fails to clamp down. Having a long labour and being obese are some of the risk factors associated with PPH.
• Several risk factors can mean the uterus does not clamp down properly. A retained or partially retained placenta may also prevent the uterus from clamping down. A large womb, such as in twin pregnancies, will take longer to contract after birth and therefore more blood may be lost.
• Rarer causes of PPH include problems with the mother’s blood that reduce its ability to clot, pre-eclampsia, placental abruption, and infection.
• The risk factors of PPH are difficult to eliminate, which is why it’s important that your risk level of PPH is detected early so that necessary preparations can be put in place.
• If you wish to have a homebirth or deliver in a birthing centre but are at a higher risk of PPH, you should have a discussion with both the doctors and midwives at your local maternity unit to discuss the risks and benefits of each option.
• The course of action will depend on how quickly blood loss occurs. Small repeated bleeds that happen over the course of an hour may not require any action from your maternal team. However, if blood loss is rapid, this is an emergency situation, and if you’re at a birthing centre or giving birth at home, your midwife will want to transfer you to an obstetric unit.
• As PPH is an emergency, your maternity team will have to work swiftly. The method used to stop the bleeding will depend on its cause, and although the procedure should be explained to you step by step, it will have to be done so very quickly.
• Your doctor or midwife may need to perform a manoeuvre called bimanual compression, which involves applying pressure to your lower belly with one hand while the other is inserted into the vagina to assist compression. Another member of your maternity team may also insert one or two drips into your hand to replace the blood already lost.
• Another injection will be given to reduce bleeding (if you’ve chosen to have an active third stage of labour, you would likely have already been given this injection).
• Further drugs that will help the uterus contract and blood to clot may be required if the bleeding continues.
• If bleeding continues or if the tear causing the bleeding is severe, you may need to be transferred to the operating theatre for a procedure, where anaesthesia will be administered.
• Although postpartum haemorrhage comes after childbirth and will not affect most elements of your birth preferences, it is likely to affect your plan immediately after the birth.
• Pregnancy prepares the body for potential blood loss by increasing how much blood is in the body by an incredible 40%, which means although excessive blood loss is a concern, women cope very well naturally with this complication.
• For large PPHs you will need closer monitoring for the first 12-24 hours to ensure that your body is coping with the blood loss.
• When at home, your body will recover and create more blood, but this can take 2-4 weeks. If you experience fresh red or heavy bleeding or blood clots bigger than 50p size, you should speak to your midwife.

References and further reading

1 – Knight M. et al (2009), Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. Nov 27;9:55
2 – Briley A. et al (2014) Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study BJOG un; 121(7): 876–888
3 – Royal College of Obstetricians and Gynaecologists (2016), Postpartum Haemorrhage, Prevention and Management (Green-Top Guideline 52) Accessible here: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/
4 – Best Practice in Labour and Delivery. p160-170. Cambridge University Press, 2010.
5 – MBRRACE-UK Report (2017) Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013–15. Accessible here: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202017%20-%20Web.pdf
6 – Managing Obstetric Emergencies and Trauma (2018) Cambridge University Press.