Postpartum haemorrhage !
Postpartum haemorrhage is heavy bleeding after birth, often because the uterus does not contract well; it is a leading cause of maternal death.
Updated 2026-10-29
Structures involved
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- Myometrium
- Body of uterus
- Fundus of uterus
- Uterine artery
- Internal iliac arteries
- Lower uterine segment
- Cervix
- Vagina
- Perineal body
In embryology
In physiology
Why it happens
- Shock: types, stages and the organs it damages
- Disseminated intravascular coagulation: how consumption causes both clots and bleeding
- Hemorrhage: petechiae, purpura, ecchymosis, hematoma, and what blood loss does
- The coagulation cascade
- The posterior pituitary: ADH and oxytocin
What it is
Excessive bleeding after birth, classically defined as cumulative blood loss of 1000 mL or more, or any loss with signs of hypovolaemia, within 24 hours. Older definitions use 500 mL after vaginal birth; criteria vary.
Who gets it
A leading cause of maternal death worldwide and in Latin America, including Colombia. Most deaths are considered preventable with active management of the third stage of labour and a rapid, organised response.
Causes
- Tone: uterine atony, the most common cause
- Trauma: tears of the cervix, vagina or perineum, uterine rupture, uterine inversion
- Tissue: retained placenta or membranes, placenta accreta spectrum
- Thrombin: coagulation disorders, inherited or acquired (DIC, HELLP, anticoagulants)
Risk factors
- Overdistended uterus: multiple pregnancy, polyhydramnios, large baby
- Prolonged or induced labour, chorioamnionitis
- Previous postpartum haemorrhage
- Placenta previa, placental abruption or accreta spectrum
- Uterine fibroids, high parity
- Operative vaginal birth or caesarean section
Pathophysiology
At term the uterus receives a large share of the cardiac output. After the placenta separates, bleeding from the placental bed stops mainly because the myometrial fibres contract and compress the spiral arteries. When the uterus does not contract, when tissue is torn or retained, or when clotting fails, blood loss can become life-threatening within minutes.
Classification
- Primary: within 24 hours of birth
- Secondary: from 24 hours up to 12 weeks after birth (often retained tissue or infection)
- By cause: the 4 T's (tone, trauma, tissue, thrombin)
Symptoms and signs
- Heavy vaginal bleeding after birth, sometimes with clots
- Soft, boggy uterus above the umbilicus (atony)
- Tachycardia and falling blood pressure
- Pallor, dizziness, sweating, anxiety or confusion
- Pain and swelling with a vaginal or perineal haematoma
Diagnosis
- Clinical
- Measured or weighed blood loss (visual estimates underestimate it), vital signs and shock index, uterine tone, inspection of the genital tract and of the placenta for missing parts.
- Tests
- Full blood count, fibrinogen and coagulation studies, blood group and crossmatch, lactate; bedside viscoelastic tests where available.
- Imaging
- Bedside ultrasound for retained tissue or haemoperitoneum; angiography when embolisation is planned.
Differential diagnosis
- Normal lochia
- Genital tract laceration or haematoma
- Uterine rupture
- Amniotic fluid embolism with coagulopathy
- Other causes of shock after birth (sepsis, pulmonary embolism)
Goal of treatment
Stop the bleeding by treating its cause, restore circulating volume and clotting, and preserve the uterus where possible.
Treatment
- Acute
- Call for help, two large-bore IV lines, warmed fluids, oxygen, blood products and a massive transfusion protocol when needed.
- Medical
- Uterotonics: oxytocin first line, then ergot alkaloids (avoided in hypertension) or prostaglandins; tranexamic acid, an antifibrinolytic, given early.
- Procedure
- Uterine massage and bimanual compression, repair of tears, manual removal of retained placenta, intrauterine balloon tamponade, uterine artery embolisation.
- Surgical
- Compression sutures, uterine or internal iliac artery ligation, and hysterectomy as a life-saving last resort.
- Procedure
- Active management of the third stage of labour for every birth: a uterotonic after delivery, controlled cord traction and checking uterine tone.
Drugs for this condition
Complications
- Hypovolaemic shock and maternal death
- Disseminated intravascular coagulation
- Transfusion reactions and acute lung injury
- Acute kidney injury
- Sheehan syndrome (pituitary necrosis)
- Loss of fertility after hysterectomy
Prognosis
With prompt recognition and treatment most women recover fully. Delays in diagnosis, transfusion or surgery are the main avoidable factors in deaths. A previous haemorrhage raises the risk in later births.
Prevention
- Active management of the third stage of labour
- Identifying risk factors and planning delivery where blood and surgery are available
- Treating anaemia during pregnancy
- Prenatal diagnosis of placenta previa and accreta spectrum
Test yourself
Think of the answer, then tap the question to see it.
What are the 4 T's of postpartum haemorrhage?
Tone (atony), trauma, tissue (retained products) and thrombin (coagulopathy).
What is the most common cause of postpartum haemorrhage?
Uterine atony.
What is the first-line uterotonic for preventing and treating postpartum haemorrhage?
Oxytocin.
Which uterotonic class is avoided in women with hypertension or preeclampsia?
Ergot alkaloids, because they cause vasoconstriction and raise blood pressure.
What are the parts of active management of the third stage of labour?
A uterotonic soon after birth, controlled cord traction and checking or massaging the uterus.
Related conditions
- Placenta praevia
- Placental abruption
- Preeclampsia
- Hypovolaemic shock
- Uterine fibroids (leiomyomas)
- Obstetric perineal tears and anal sphincter injury
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Postpartum Hemorrhage (StatPearls (NCBI Bookshelf), 2024).
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Representative model, for educational purposes only.
