Postpartum haemorrhage

It’s normal to have some bleeding from your vagina after birthing your baby — this bleeding is known as 'lochia'. It usually comes from the area of your uterus where the placenta was attached and this wound needs to heal like any other abrasion or cut. You may also have bleeding from any tears or cuts that happened during birth.

Bleeding will typically be heaviest in the first few days after birth and slowly reduce over the next days and weeks.

Vaginal bleeding is often bright red, like a heavy period, in the first few days after birth. The colour of your blood loss may change over time from bright red to pinkish-brown and eventually whitish-yellow as your bleeding slows down and eventually stops. The colour of blood lost can vary from person to person.

Bleeding after birth typically lasts up to 6 weeks, although this varies.

You may have heavier bleeding in the morning when you get out of bed, after exercise and after breastfeeding.

Postpartum haemorrhage is when you bleed more than normal after giving birth. It's defined as losing more than 500mL (half a litre) of blood from your vagina after birth.

Postpartum haemorrhage is serious and can be life-threatening. You need urgent medical attention to stop the bleeding.

Postpartum haemorrhage within the first 24 hours after the birth is called a primary postpartum haemorrhage. Postpartum haemorrhage more than 24 hours but less than 6 weeks later is called a secondary postpartum haemorrhage.

Postpartum haemorrhage is the most common serious complication of childbirth and happens in 5 to 15 out of every 100 births in Australia. Most of the time it happens within the first 24 hours.

If you have given birth within the last 6 weeks and you are bleeding heavily from your vagina, go to the emergency department. If you feel unwell or have given birth within the last 24 hours, call triple zero (000) immediately and ask for an ambulance.

Although bleeding after birth is normal, you may be having postpartum haemorrhage if you gave birth more than 24 hours ago and:

• you are soaking through a pad every hour or two
• you are passing large clots
• the blood suddenly changes to bright red in colour
• the amount of blood loss suddenly increases
• you feel tired, dizzy or are having trouble breathing
• you are concerned about your blood loss

Depending on what’s causing your bleeding, you might also experience:

• fever
• pain in your lower abdomen
• an unpleasant smell with the bleeding

If you are bleeding heavily (soaking through a pad every hour or two) and you have given birth within the last 6 weeks, go to your hospital's emergency department straight away.

Call triple zero (000) and ask for an ambulance if you:

• have given birth within the last 24 hours
• feel unwell, dizzy or clammy
• feel your heart racing
• are short of breath

Contact your doctor or midwife immediately if you:

• are unsure whether your bleeding is normal
• have a temperature over 37.5°C or chills
• notice any unusual discharge from your vagina
• have worsening abdominal pain
• have bad smelling blood loss

The most common cause of primary postpartum haemorrhage (occurring in the first 24 hours after birth) is your uterus (womb) not contracting as it should. Normally, the uterus contracts to push out the placenta and stop bleeding from the large blood vessels that supplied blood to the placenta. If your uterus does not contract well, these blood vessels can continue to bleed.

It can also happen due to:

• an injury to your uterus, cervix, vagina or perineum
• part or all of the placenta not coming out of the uterus
• problems with blood clotting

The most common cause of secondary postpartum haemorrhage (occurring between 24 hours and 6 weeks after birth) is an infection in the uterus — this can be due to part of the placenta being left inside your uterus.

Secondary postpartum haemorrhage can occasionally be caused by other problems, such as fibroids.

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

However, it is more likely if you have:

• given birth 5 or more times before — the risk goes up with each birth
• a very stretched uterus — for example, if you are carrying a large baby  (more than 4kg) or multiple babies or if you have a lot of amniotic fluid
• a problem with how or where the placenta is attached to your uterus, such as placenta praevia
• a bleeding disorder
• had a postpartum haemorrhage before
• uterine fibroids (Opens in new tab)
• other health conditions — such as a BMI over 35, high blood pressure, anaemia or diabetes

The type of birth you have can also increase your risk of a postpartum haemorrhage. You are at a higher risk if:

• you have either a long labour (more than 12 hours) or a very fast labour
• you are induced to start labour
• you have an assisted birth with forceps or vacuum or a caesarean
• you have an episiotomy
• part or all of the placenta doesn't come out after birth
• you have a fever during labour
• your baby's shoulders get stuck in the birth canal during birth

Primary postpartum haemorrhage

Primary postpartum haemorrhage is a medical emergency. To treat it, your medical team will need to insert a needle into your vein (called an IV) to provide you with fluids. They may need to insert a catheter (tube) into your bladder to monitor your urine.

They will examine you to find the cause of the bleeding. They will monitor you closely by checking your blood pressure and pulse.

Treatment of postpartum haemorrhage depends on what is causing it and how much blood you have lost. It may include:

• massaging your uterus by pressing on your abdomen — this will help it contract and push the placenta out
• medicines to reduce the bleeding
• a blood transfusion (Opens in new tab)
• surgery in an operating room under anaesthetic

If you need surgery, it may involve:

• removing the placenta or any membranes or blood clots remaining in your uterus
• repairing any injuries causing bleeding
• inserting a balloon into your uterus to put pressure on the bleeding area
• hysterectomy (Opens in new tab) (removing the uterus) — in very rare cases, this may be the only way to stop the bleeding and save your life

After surgery, you will be closely monitored in hospital, often in an intensive care unit (ICU) (Opens in new tab).

Learn about giving informed consent for treatment.

Secondary postpartum haemorrhage

Secondary postpartum haemorrhage that starts more than 24 hours after giving birth is usually treated with antibiotics. You may also need medicine to help your uterus contract, or surgery to remove any tissue that is still inside your uterus.

If you have lost a lot of blood, you may need additional treatment, like fluids, medicines or a blood transfusion.

Postpartum haemorrhage is unpredictable, so it’s important that everyone giving birth has access to emergency medical care after having their baby.

Doctors and midwives usually recommend having medicine during the third stage of labour to help you birth the placenta, instead of waiting for it to come out on its own. This can reduce your chance of having a postpartum haemorrhage. You can speak with your doctor or midwife about this before labour. This discussion may help you decide what is right for you.

It’s very important that you have an ultrasound during pregnancy to check the position of your placenta. If you have placenta praevia, you may be able to make a plan for birth to help avoid life-threatening bleeding.

If you are at a higher risk of having postpartum haemorrhage, your doctor or midwife will discuss with you where it is safest for you to give birth. You might be advised to have an intravenous cannula (IV) inserted during labour in case you need medicines or fluids urgently.

After a postpartum haemorrhage some other problems are more likely.

Anaemia

If you lose a lot of blood, you might develop anaemia (Opens in new tab) (low red blood cells). You may feel tired, dizzy and emotional for weeks if you have anaemia. Your doctor can check for anaemia with a blood test. You may need iron therapy (Opens in new tab) or a blood transfusion. It can also help to eat foods that are high in iron.

Breastfeeding difficulties

Sometimes breastfeeding is more difficult after a postpartum haemorrhage. Losing blood due to a postpartum haemorrhage can affect your body’s ability to make milk. Speak to your doctor, midwife or a lactation consultant if you are having trouble with breastfeeding or worried your baby isn’t getting enough breastmilk.

Blood clots

Having a postpartum haemorrhage increases your risk of developing a blood clot. You can reduce your chance of developing a clot by staying active and drinking plenty of water. Speak to your doctor to see if there’s anything else you should do to prevent blood clots.

Stress, anxiety or trauma

Having a postpartum haemorrhage increases your chance of developing post-traumatic stress disorder (PTSD). This is when fear and anxiety don’t go away after experiencing a traumatic event. If you are feeling negative emotions after a postpartum haemorrhage, talk to your doctor or midwife. It can help to talk to someone. Your partner may also develop PTSD and should speak to a doctor.

You have a higher chance of having another postpartum haemorrhage in future pregnancies if you have had one before, so it’s very important to let your medical team know during your next pregnancy. They can make a plan with you to reduce your chance of having a postpartum haemorrhage again.

After you have had a postpartum haemorrhage, ask your doctor or midwife for a debrief session to talk through what happened, even if it’s weeks later. They can explain what happened and may be able to ease your concerns. Your partner may also have found the experience traumatic and need to talk about it.

If you’re worried about the possibility of a postpartum haemorrhage in future pregnancies, talk to your doctor or midwife.

Talk to your doctor or midwife if you have any concerns about postpartum haemorrhage or if you want to talk about what happened after the event.

If you have experienced a postpartum haemorrhage and are finding it hard to cope, you can call or visit:

• Perinatal Anxiety and Depression Australia (PANDA) (Opens in new tab) on 1300 726 306
• Birth Trauma Australia (Opens in new tab)
• Beyond Blue (Opens in new tab) on 1300 22 4636