Postpartum haemorrhage

What is postpartum haemorrhage?

Postpartum haemorrhage is when you bleed more than normal after giving birth. It's defined as passing more than 500ml of blood from your vagina after having a baby.

If this bleeding occurs in the first 24 hours after the birth, it's called a primary postpartum haemorrhage. If it occurs more than 24 hours but within 6 weeks after birth, it's called a secondary postpartum haemorrhage.

Postpartum haemorrhage is very serious and can be life threatening. Medical attention is needed very quickly to stop the bleeding.

Postpartum haemorrhage happens after 5 to 15 out of every 100 births in Australia.

What causes postpartum haemorrhage?

Postpartum haemorrhage is most often caused by your uterus (womb) not contracting as it should after the birth. When your uterus contracts, it helps push the placenta out and reduces bleeding from the large blood vessels that delivered blood to the placenta. If your uterus doesn’t contract properly, those blood vessels can continue to bleed.

It can also be caused by an injury to your uterus, cervix, vagina or perineum. In other cases, it is caused by a problem with the placenta such as placenta praevia, placental abruption, placenta accreta or retained placenta.

Who is likely to have a postpartum haemorrhage?

Most people who have a postpartum haemorrhage don't have any known risk factors. It can happen to anyone and it's unpredictable.

However, it is more likely if you have:

• given birth 3 or more times previously – the risk goes up the more times you have given birth
• a very stretched uterus (for example, if you are carrying a large baby or multiple babies or you have a lot of amniotic fluid)
• a problem with the way the placenta is attached to your uterus
• a bleeding disorder
• had a postpartum haemorrhage before
• uterine fibroids
• other health conditions, for example, a BMI over 35, high blood pressure, anaemia, or diabetes

You have also at a higher risk of a postpartum haemorrhage if:

• you have a very long or very fast labour
• you are induced to go into labour
• your baby is delivered by forceps, vacuum or caesarean
• part or all of the placenta doesn't come out
• you develop an infection
• your baby's shoulders get stuck in the birth canal during delivery

Can postpartum haemorrhage be prevented?

Because postpartum haemorrhage is so unpredictable, it’s important that anyone giving birth has access to emergency medical care after they have their baby.

You will be offered an injection of a medicine containing oxytocin once your baby is born, to help your uterus contract. This can lower your risk of postpartum haemorrhage by half.

Your midwife or doctor can actively help deliver the placenta rather than waiting for it to come out by itself. If your doctor or midwife thinks you are at increased risk of postpartum haemorrhage, they may recommend you give birth in a major hospital with blood products ready in case you need a blood transfusion.

It’s very important that you have an ultrasound during pregnancy to see where your placenta is located and check whether you are at high risk of severe bleeding.

How is primary postpartum haemorrhage treated?

Postpartum haemorrhage is a medical emergency. To treat it, your medical team will insert an IV needle into a vein and possibly a catheter into your bladder. They will examine you to find the cause of the bleeding and keep a close eye on your blood pressure and pulse.

Treatments for postpartum haemorrhage include:

• massaging your uterus to help it contract and help the placenta come out
• giving you fluids through your IV
• giving you medicines to reduce bleeding
• offering you a blood transfusion

If the bleeding still can’t be controlled, you may need to have surgery to remove the placenta or any remaining tissue, or to repair an injury that’s causing the bleeding. There are other surgical procedures that can stop bleeding, such as inserting a surgical balloon into your uterus. Sometimes the only way to stop the bleeding and save your life might be to remove your uterus (hysterectomy).

Afterwards, you will need to be closely monitored in hospital, sometimes in an intensive care unit (ICU).

How is secondary postpartum haemorrhage treated?

Postpartum haemorrhage that begins more than 24 hours after giving birth is usually caused by an infection or retained tissue in your uterus. It is usually treated with antibiotics. You may need to have medicine to help your uterus contract or an operation to remove any tissue still inside your uterus.

If you are very unwell from blood loss, you may need the same treatment as for primary postpartum haemorrhage.

How do I know if I’m bleeding too much?

While bleeding after giving birth is normal, you may have a postpartum haemorrhage if:

• you are soaking through a pad every hour or two
• you are passing blood clots
• the blood you pass becomes bright red

Can postpartum haemorrhage cause any other problems?

If you lose a lot of blood, you might develop anaemia. Your doctor can check this with a blood test. You may need to have iron therapy or a blood transfusion.

Sometimes breastfeeding is more difficult after a postpartum haemorrhage. Speak to your midwife if you are having trouble with breastfeeding.

If you’ve had a postpartum haemorrhage you have a higher risk of developing a blood clot. It’s important to stay active and drink plenty of water. Speak to your doctor to see if there’s anything else you should do to prevent blood clots.

People whose labour didn't go to plan may feel negative emotions about their birth experience. You may feel upset or anxious about what happened. It can help to talk to someone.

You can seek advice or support from:

• The medical team who cared for you during your postpartum haemorrhage
• Your doctor or midwife
• Perinatal Anxiety and Depression Australia (PANDA) on 1300 726 306
• Australasian Birth Trauma Association
• Beyond Blue on 1300 22 4636

You can call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436.

When should I see a doctor?

If you have recently given birth, you should see your doctor immediately if you have:

• increased bleeding
• fever
• shortness of breath
• pain, redness or swelling in your leg

You should also see your doctor if you’re feeling very tired or anxious.

Will postpartum haemorrhage affect my pregnancies in the future?

You are at increased risk of having another postpartum haemorrhage next time. It’s very important to tell your medical team during your next pregnancy, so they can try to prevent it from happening again.

If you’re worried about the possibility of a postpartum haemorrhage in future pregnancies, it can help to talk to your doctor or midwife so they can explain what happened.