Postpartum hemorrhage (PPH) is excessive blood loss that happens after a mother gives birth, which can cause serious, sometimes life-threatening, problems. If too much blood is lost, the heart isn’t able to effectively pump blood to all the vital organs, resulting in an emergency.
Excessive blood loss is defined by the American College of Obstetricians and Gynecologists as more than 1,000 milliliters (1 liter) of blood lost within 24 hours after delivery. While maternal hemorrhage is most likely to occur within the first 24 hours postpartum, excessive bleeding can also occur later, up to 12 weeks after delivery. Hemorrhage that occurs beyond 24 hours after delivery is known as late or delayed postpartum hemorrhage.
Postpartum hemorrhage occurs in 4% of pregnancies and is a significant problem worldwide, responsible for one in four maternal deaths. In the United States, the likelihood of death and suffering due to PPH has decreased since the 1990s but is still responsible for about one in ten deaths from childbirth-related causes. Some experts estimate that somewhere between 54 to 93% of these deaths may be preventable.
While both early and late postpartum hemorrhage are of significant concern to patients and healthcare providers alike, the term postpartum hemorrhage in this article will refer to excessive blood loss that occurs within the first 24 hours after delivery.
Risk factors are certain conditions or characteristics that tend to be associated with a particular health problem. Risk factors may not cause the problem, but they may directly or indirectly increase the chance you’ll experience it. However, just because you have one or more risk factors doesn’t mean you’re sure to develop the problem.
Risk factors making it more likely for a mother to experience postpartum hemorrhage include:
Certain conditions of the placenta and uterus are also known to increase the risk of obstetric hemorrhage:
While there are known risk factors that can increase the likelihood a mother will experience excessive bleeding during or after birth, it’s important to keep in mind that two-thirds of postpartum hemorrhages occur in women with no known risk factors. In other words, every delivery brings with it the risk of bleeding, and healthcare providers must remain vigilant in preventing, recognizing, and treating obstetric hemorrhage.
While many risk factors are known prior to delivery and indirectly associated with postpartum hemorrhage, the most common causes are more directly correlated. Often, a situation develops during labor or delivery, and it isn’t necessarily an event that can be predicted or expected.
The most common cause of postpartum hemorrhage is uterine atony, when the uterus doesn’t contract or tighten after birth to help control the bleeding.
After a baby is born, the uterus normally contracts to help push out the placenta. These contractions also serve to put pressure on the blood vessels that once connected mom to baby to help stop the bleeding. Without this pressure, bleeding may continue.
The placenta is usually delivered, on average, within eight to nine minutes after the baby is born. The likelihood of hemorrhage doubles if the placenta is not delivered after 10 minutes. If the placenta or any part of the placenta is retained, it prevents effective uterine contractions, which can result in heavy bleeding.
Other common causes include cuts or tears in tissue from trauma during delivery and problems with blood clotting.
Rarely, other conditions of the uterus such as uterine rupture (when the uterus tears during labor) or uterine inversion (when the uterus turns inside out) can cause excessive bleeding.
It is normal to have some blood loss during delivery, whether the birth is vaginal or by cesarean section. In vaginal births, women may lose up to 500 milliliters (half a liter) of blood. In a cesarean section, it’s normal to have more blood loss, up to 1,000 milliliters (one liter). Greater than 1,000 milliliters of blood loss is considered excessive and an indication of postpartum hemorrhage.
Some signs and symptoms of hemorrhage include:
Nearly all of the signs and symptoms of postpartum hemorrhage are identifiable only after a significant amount of blood has been lost. By that time, a mother may be at risk for severe complications.
Studies show that quick recognition and accurate assessment of blood loss is a key factor in preventing complications, but what’s the best way to achieve this?
There are two strategies currently used in hospital systems:
Visual estimation of blood loss— when a caregiver looks at the amount of blood lost and makes an estimate of the blood volume based on what they see.
Quantification of blood loss—when a caregiver employs a systematic method for measuring the amount of blood lost, which can be achieved in different ways with varying degrees of accuracy.
One commonly used method for quantification involves measuring the weight of blood-soaked cloths and subtracting the dry weight to estimate the volume of blood. Other methods employ various collection containers to measure blood loss or spectrophotometry to measure hemoglobin levels. Several clinical studies have demonstrated that quantification of blood loss is more accurate than visual estimation. Almost universally, visual estimation leads to an underestimation of blood loss by as much as 35 to 50%.
While quantification of blood loss gives a better blood loss estimate, it often requires more time and effort of hospital staff. Furthermore, it has not been clear which method of quantification is most effective.
Bleed ID offers a novel way of recognizing and quantifying blood loss without adding complexity and time-consuming tasks to the already over-taxed nursing and medical staff.
Delayed recognition of excessive bleeding and imprecise measurement of the amount of blood lost are two of the most important clinical factors contributing to a delayed response to postpartum hemorrhage. Bleed ID targets these pain points directly in order to recognize and treat excessive blood loss quicker and more effectively.
PPH is diagnosed in women with heavier bleeding than expected (more than 1,000 milliliters within the first 24 hours after birth) and who show signs and symptoms of low blood volume.
Signs and symptoms of low blood volume may include:
Severe postpartum hemorrhage can lead to complications such as hypovolemic shock (when low blood volume keeps your heart from pumping blood), organ failure, blood transfusion complications, edema (swelling), compartment syndrome (excessive pressure inside a confined space within the body), blood clots, acute respiratory distress syndrome (fluid build-up in the lungs), anemia, sepsis (blood infection), prolonged hospitalization, and death.
There are three basic steps that must occur in treating PPH:
Since uterine atony is the most common cause of postpartum hemorrhage, medications that induce uterine contraction and improve uterine tone are often used. This includes medications such as oxytocin, misoprostol, methylergonovine, dinoprostone, and carboprost tromethamine. Uterine massage and other types of compression techniques are also used to induce uterine contractions.
It is sometimes necessary for a healthcare practitioner to manually remove the placenta, remaining parts of the placenta, or blood clots that can cause bleeding to continue.
Medications that help with blood clotting can be used, such as recombinant activated factor VIIa and tranexamic acid.
More invasive procedures and surgical interventions such as hysterectomy are employed when other techniques are unsuccessful.
General interventions such as blood transfusion and fluid replacement are often used as well.
Please note this is not an exhaustive list of treatment options but a simplified summary of common treatments.
There are three defined stages of labor:
According to the American Academy of Family Physicians, active management of the third stage of labor is the most effective way to prevent postpartum hemorrhage and also reduces the need for manual removal of the placenta.
After the baby is delivered, active management of this third stage of labor includes administering oxytocin or an alternative when or shortly after the baby’s upward-facing shoulder is delivered. This causes the uterus to contract and helps to deliver the placenta.
Doctors may also perform a procedure called controlled cord traction, where the umbilical cord is clamped and pulled, applying counter pressure to help deliver the placenta.
Uterine massage after delivery of the placenta is the third component to active management of the third stage of labor. This also can help stimulate the uterus to contract, placing pressure on blood vessels, which in turn, helps slow the bleeding.