Postpartum bleeding

Postpartum bleeding is vaginal blood loss after the third stage of labour. Primary postpartum haemorrhage is blood loss of 500 mL or more after vaginal birth (1000 mL or more after caesarean section) within 24 hours of birth, or any loss that causes haemodynamic change. Secondary postpartum haemorrhage is abnormal or excessive bleeding from 24 hours to 12 weeks after birth.

The main clinical points are:

• Recognise haemorrhage early by measuring blood loss and watching the shock index.
• Find and treat the cause by the four Ts (tone, trauma, tissue, thrombin).
• Resuscitate and give uterotonics and tranexamic acid at once.
• Escalate quickly from medical to surgical measures.
• Replace blood and clotting factors in a planned way.

Clinical relevance. Postpartum haemorrhage is the leading direct cause of maternal death worldwide. It is a major cause of severe morbidity (transfusion, hysterectomy, renal failure, Sheehan syndrome, anaemia). Most deaths occur within 4 hours of birth and are preventable.

Physiology.

• Blood volume rises by 40 to 50% in pregnancy, so healthy women tolerate the loss of 1000 mL before showing signs. Uterine blood flow at term is 500 to 800 mL/min.
• Haemostasis after delivery depends on uterine contraction compressing the spiral arteries, fibrinogen (which rises to 4 to 6 g/L at term), and prompt clot formation.
• Lochia is normal postpartum discharge: red for 3 to 4 days (lochia rubra), pink brown to 10 to 14 days, and pale yellow white (alba) for up to 4 to 6 weeks.
• A return of heavy bleeding with clots after the first week, or a foul smell, is abnormal.

Mechanisms. The four Ts:

• Tone: uterine atony, 70% of cases.
• Trauma: cervical, vaginal and perineal tears, uterine rupture, uterine inversion, haematoma.
• Tissue: retained placenta or membranes, placenta accreta.
• Thrombin: coagulopathy, inherited or acquired, dilutional or consumptive, from abruption, sepsis, amniotic fluid embolism, pre eclampsia, HELLP syndrome or anticoagulants.

Classification. Primary (within 24 hours) and secondary (24 hours to 12 weeks). By cause: the four Ts. By volume:

• minor (500 to 1000 mL)
• major (over 1000 mL, moderate 1000 to 2000 mL, severe over 2000 mL)
• massive (loss of one blood volume or replacement of 10 units within 24 hours, or 50% of blood volume within 3 hours)

Key distinctions.

• A soft, boggy fundus with bleeding indicates atony.
• A firm contracted uterus with continuous bright red bleeding indicates trauma.
• An incomplete placenta or membranes indicates tissue.
• Failure to clot or oozing from sites indicates coagulopathy.
• Normal lochia does not need treatment.
• Bleeding after 24 hours with fever or a tender uterus suggests infection and retained products.

History

• Birth details: gestation, mode and duration of labour, induction, oxytocin augmentation, instrumental delivery, caesarean section, episiotomy or tears, placental delivery and completeness, third stage management, blood loss recorded.
• Antepartum risk factors: previous postpartum haemorrhage, previous caesarean section or uterine surgery, multiple pregnancy, polyhydramnios, large baby, high parity, antepartum haemorrhage, placenta praevia or accreta, anaemia, pre eclampsia, obesity, fibroids, bleeding disorder, anticoagulant use, age over 35.
• Intrapartum risk factors: prolonged labour, chorioamnionitis, magnesium sulphate, general anaesthesia, retained placenta, uterine inversion.
• Secondary bleeding: day after birth, pattern, clots, smell, fever, abdominal pain, wound problems, breastfeeding, menstruation, lochia colour, contraceptive use, tampon or pad count.
• Symptoms of anaemia and shock: dizziness, palpitations, breathlessness, fatigue, chest pain, headache, faintness.
• Medical and drug history: von Willebrand disease, haemophilia carrier status, thrombocytopenia, liver disease, aspirin, enoxaparin, NSAIDs, antidepressants.
• Social: access to a facility, transport, home birth.

Examination

• Airway, breathing, circulation; heart rate, blood pressure, shock index (heart rate divided by systolic pressure; over 0.9 is abnormal and over 1.4 predicts transfusion), respiratory rate, capillary refill, temperature, mental state, urine output, pallor.
• Quantify blood loss by weighing swabs and pads (1 g equals about 1 mL), collecting in a graduated drape, and estimating concealed loss.
• Uterus: height of fundus, tone (firm or boggy), tenderness, and whether it is displaced by a full bladder; check for uterine inversion (absent fundus, mass in the vagina).
• Placenta and membranes: completeness.
• Lower genital tract: inspect the perineum, vagina and cervix with good light, analgesia and a speculum; check for haematoma.
• Bimanual compression if the uterus is atonic.
• Coagulation: bedside clotting observation (2 mL of blood in a clean glass tube; no clot at 7 minutes, or a soft clot that breaks down, suggests coagulopathy).
• Secondary bleeding: abdominal tenderness, uterine subinvolution, cervical os open, foul lochia, wound, breasts, calves.

Red flags

• Blood loss over 1000 mL, or any loss with shock index over 0.9.
• Heart rate over 100 beats/min, systolic pressure under 100 mmHg, pallor, cold peripheries, confusion, fainting, oliguria.
• Persistent bleeding despite uterotonics, a boggy uterus, or a firm uterus with continuous bright red bleeding.
• Expanding vulval, vaginal or abdominal swelling with pain (haematoma), rectal pressure.
• Failure of blood to clot, widespread oozing, petechiae (disseminated intravascular coagulation).
• Uterine inversion, suspected uterine rupture, or retained placenta over 30 minutes.
• Known placenta accreta, praevia, abruption, pre eclampsia, HELLP syndrome, or anticoagulant use.
• Fever, foul lochia and bleeding after 24 hours (endometritis).
• Late bleeding with a positive pregnancy test (molar disease or choriocarcinoma).

Special groups.

• Women with anaemia (haemoglobin under 100 g/L) tolerate loss poorly.
• Jehovah's Witnesses and others declining blood need early planning (cell salvage, intravenous iron, tranexamic acid, early surgery).
• Women with bleeding disorders need specialist haematology plans.
• Postpartum women with pre eclampsia: avoid ergometrine and manage fluids carefully.
• Region specific: home and rural birth, absence of blood, long transfer; use uterine massage, uterotonics, tranexamic acid, bimanual compression, aortic compression and an anti shock garment while arranging transfer.

Organised by the four Ts and by the time of the bleeding. Each cause is common unless marked serious or uncommon.

Tone (uterine atony)

• Uterine atony from overdistension (multiple pregnancy, polyhydramnios, large baby), prolonged or augmented labour, high parity, chorioamnionitis, anaesthetic agents, magnesium sulphate.
• Full bladder preventing contraction.
• Fibroids or uterine anomaly interfering with contraction.
• Retained placenta or clots keeping the uterus soft.

Trauma

• Perineal, vaginal and cervical tears; episiotomy extension.
• Vulval, vaginal or paravaginal haematoma.
• Serious: uterine rupture (scar dehiscence after previous surgery).
• Serious: uterine inversion.
• Serious: broad ligament haematoma, intra abdominal bleeding after caesarean section.
• Surgical bleeding after caesarean section (uterine angle extension, bladder flap, epigastric vessel injury).

Tissue

• Retained placenta, retained cotyledon or membranes.
• Serious: placenta accreta, increta, percreta (adherent placenta).
• Retained products after miscarriage or termination.
• Placental polyp.

Thrombin and coagulation

• Serious: disseminated intravascular coagulation from abruption, sepsis, amniotic fluid embolism, intrauterine death, severe pre eclampsia and HELLP syndrome, acute fatty liver.
• Dilutional coagulopathy after massive transfusion or fluid replacement.
• Inherited bleeding disorders: von Willebrand disease (bleeding rises as von Willebrand factor falls postpartum), haemophilia carrier, factor XI deficiency, platelet disorders.
• Thrombocytopenia (immune, gestational, HELLP).
• Anticoagulant or antiplatelet drug effect (enoxaparin, aspirin).

Secondary (24 hours to 12 weeks) bleeding

• Endometritis, with or without retained products.
• Subinvolution of the placental site.
• Retained placental tissue or membranes.
• Dehiscence of a caesarean scar or uterine wound with haematoma.
• Normal lochia, including a late rise in loss with activity in weeks 1 to 2.
• Return of menstruation (non breastfeeding women from 4 to 8 weeks).
• Hormonal contraception related breakthrough bleeding.
• Gestational trophoblastic disease, choriocarcinoma.
• Uterine arteriovenous malformation, uterine artery pseudoaneurysm (sudden severe bleeding).
• Cervical or vaginal tear breaking down, cervical ectropion, polyp.
• Vaginal infection, cervicitis.
• Disseminated coagulopathy, von Willebrand disease.
• Uterine tumour and cervical cancer (rare).

Stepwise reasoning

1. Recognise haemorrhage early by quantifying loss and tracking shock index.
2. Resuscitate and call for help while searching for the cause.
3. Assess the four Ts systematically: tone (palpate), trauma (examine), tissue (inspect placenta, ultrasound), thrombin (clotting test, bloods).
4. Treat the identified cause with escalating measures; do not wait for laboratory results to act.
5. Reassess after each step; if bleeding continues, move to the next step quickly.

First line tests

• Full blood count, group and crossmatch (4 to 6 units for major haemorrhage), coagulation screen, fibrinogen (a Clauss level under 2 g/L predicts progression to severe haemorrhage; the target is over 2 g/L), urea, creatinine, electrolytes, liver function tests, lactate, blood gas, ionised calcium.
• Point of care viscoelastic testing (thromboelastography or rotational thromboelastometry) where available.
• Bedside clotting observation (2 mL of blood in a clean glass tube) in settings without a laboratory.
• Kleihauer test in rhesus negative women.
• Pregnancy test or serum human chorionic gonadotropin in secondary bleeding.

Targeted tests

• Ultrasound for retained products (thickened, echogenic endometrial cavity with vascularity), uterine haematoma, scar niche, intra abdominal fluid after caesarean section.
• Speculum swabs and endocervical swabs for infection; blood cultures if febrile.
• Colour Doppler or CT angiography for arteriovenous malformation or pseudoaneurysm (do not curette; refer for embolisation).
• MRI in selected women.
• Histology of the placenta and any tissue removed.
• Von Willebrand factor antigen and activity, factor VIII and platelet function testing 6 weeks or more after birth for suspected inherited disorder.
• Thyroid, iron studies and ferritin after the acute event.

Limitations. Visual estimates of blood loss under count by up to 50%. Vital signs lag behind loss in young healthy women. Haemoglobin may not fall for hours after acute loss. Laboratory results lag behind bleeding, so management must start before results return. Conventional clotting screens are insensitive in obstetric haemorrhage; fibrinogen is more useful.

Immediate steps (do together).

• Call for help (obstetrician, anaesthetist, midwife in charge, haematologist, blood bank).
• Lay the woman flat with legs raised if hypotensive. Give oxygen 10 to 15 L/min by mask.
• Establish two large bore cannulae (14 or 16 gauge) and take bloods.
• Start warmed crystalloid. When loss exceeds 1500 mL or there is shock, activate the massive haemorrhage response and issue blood (O rhesus negative if group is not known, and group specific as soon as available).
• Insert a urinary catheter, empty the bladder and measure urine output.
• Keep the woman warm. Record times and doses.

Stage 1: uterine tone

• Rub up a contraction (uterine massage) and expel clots.
• Oxytocin 10 units intramuscularly or 5 units by slow intravenous injection over 1 to 2 minutes. Then give an infusion of 40 units in 500 mL sodium chloride 0.9% at 125 mL/h (10 units/h) for 4 hours. Avoid rapid bolus because of hypotension.
• Ergometrine 0.2 mg (or 0.5 mg in some services) intramuscularly or by slow intravenous injection, repeated after 2 hours if needed (maximum 5 doses in 24 hours). Avoid in hypertension, pre eclampsia, heart disease and migraine.
• Carboprost 250 microgram intramuscularly every 15 minutes (maximum 8 doses, 2 mg). Avoid in asthma. Expect nausea, vomiting, diarrhoea and bronchospasm.
• Misoprostol 800 microgram sublingually (or 1000 microgram rectally) once. Expect shivering and fever. Use in settings without injectable drugs or in addition to other drugs.
• Tranexamic acid 1 g intravenously over 10 minutes within 3 hours of birth, repeated once after 30 minutes if bleeding continues (reduce the dose to 10 mg/kg in renal impairment).
• Bimanual compression or aortic compression while waiting.

Stage 2: trauma and tissue

• Examine under good light and repair tears. Use absorbable 2/0 or 3/0 suture. Give 1 g of paracetamol before. Use local anaesthetic lidocaine 1% up to 3 mg/kg without adrenaline in the lower tract.
• Remove the retained placenta or tissue manually or by suction under regional or general anaesthesia. Give prophylactic antibiotics (cefazolin 2 g intravenously once, with metronidazole 500 mg intravenously).
• Haematoma: incise and drain, ligate bleeding vessels and pack when large or expanding.
• Uterine inversion: stop oxytocin and replace the uterus immediately by manual pressure (Johnson manoeuvre).
• If replacement is difficult, give glyceryl trinitrate 50 to 100 microgram intravenously or terbutaline 0.25 mg subcutaneously to relax the uterus. Alternatively use hydrostatic replacement (O'Sullivan) with warm sodium chloride 0.9% 2 to 3 L.
• After replacement, give oxytocin and uterotonics.
• Suspected rupture or intra abdominal bleeding: laparotomy.

Stage 3: refractory atony (no response to drugs)

• Intrauterine balloon tamponade (Bakri or an improvised condom catheter), filled with 300 to 500 mL of warm saline until bleeding stops. Do not exceed the maximum volume stated for the device.
• Leave the balloon for 12 to 24 hours with oxytocin infusion and antibiotics (cefazolin 2 g intravenously every 8 hours for 24 hours). Remove gradually.
• Uterine compression sutures (brace sutures), uterine artery and utero ovarian ligation, internal iliac artery ligation.
• Interventional radiology embolisation of the uterine arteries if the woman is stable and the service is available.
• Hysterectomy (subtotal or total) without delay when bleeding is life threatening, in placenta accreta, uterine rupture beyond repair, or after failed conservative measures.
• Non pneumatic anti shock garment and aortic compression to buy time in transfer.

Transfusion and clotting support

• Haemoglobin target: transfuse red cells when haemoglobin is under 70 g/L, or earlier with ongoing bleeding or symptoms.
• In massive haemorrhage give red cells, plasma and platelets in a balanced ratio (for example 4 units of red cells, 4 units of plasma, and 1 adult dose of platelets). Reassess every 4 units.
• Fibrinogen: give fibrinogen concentrate 2 to 4 g or cryoprecipitate 2 pools (about 10 units) when fibrinogen is under 2 g/L. Give empirically when bleeding is brisk and no result is available. Measure again.
• Platelets: keep above 50 x 10^9/L (above 75 x 10^9/L in ongoing bleeding).
• Prothrombin time: fresh frozen plasma 15 mL/kg when the ratio exceeds 1.5.
• Calcium: calcium gluconate 10% 10 mL intravenously for every 4 units of red cells, to keep ionised calcium above 1.1 mmol/L.
• Keep temperature over 36°C, pH over 7.2, and correct acidosis.
• Cell salvage where available and acceptable. Recombinant activated factor VII is a last resort in selected cases with specialist advice.
• Anti D immunoglobulin for rhesus negative women with a rhesus positive baby: at least 500 IU intramuscularly within 72 hours, increased by 125 IU for each 1 mL of foetal red cells above 4 mL.

Secondary postpartum haemorrhage

• Resuscitate if needed. Examine. Ultrasound. Full blood count. Swabs and blood culture.
• Antibiotics for suspected endometritis: clindamycin 900 mg intravenously every 8 hours with gentamicin 5 mg/kg intravenously once daily. Add ampicillin 2 g intravenously every 6 hours if there is no response. Oral step down: co-amoxiclav 625 mg orally every 8 hours for 5 to 7 days.
• Oxytocin or ergometrine if the uterus is lax.
• Tranexamic acid 1 g intravenously over 10 minutes, then 1 g orally every 8 hours (or 1 to 1.5 g orally three times daily) for 3 to 5 days.
• Evacuation of retained tissue under antibiotic cover when ultrasound shows retained products and bleeding is heavy. Send tissue for histology. Avoid curettage of a suspected arteriovenous malformation.
• Misoprostol 800 microgram sublingually may be used for small retained products with bleeding when the woman is stable, with follow up scan.
• Hysteroscopy or surgical management for niche or scar dehiscence.
• Contraception: progestogen or intrauterine methods after bleeding settles. Combined hormonal contraception only after 6 weeks, and not if risk factors for venous thromboembolism.

After the haemorrhage

• Thromboprophylaxis once bleeding is controlled: enoxaparin 40 mg subcutaneously once daily (20 mg under 50 kg; 60 mg for 91 to 130 kg). Start 12 to 24 hours after bleeding has stopped, with stockings or intermittent pneumatic compression, for 10 days to 6 weeks.
• Iron: ferric carboxymaltose 1000 mg intravenously once (maximum 20 mg/kg) when haemoglobin is under 100 g/L, or oral elemental iron 65 mg once daily or 100 mg on alternate days for 3 months. Recheck haemoglobin at 2 to 4 weeks and ferritin at 8 to 12 weeks. Vitamin B12 and folate if indicated.
• Monitor for Sheehan syndrome: failure of lactation, amenorrhoea, fatigue, hypotension, hyponatraemia, hypoglycaemia. Test cortisol, thyroid stimulating hormone, free thyroxine and prolactin.
• Breastfeeding is encouraged. Most drugs used are compatible.
• Debrief: explain what happened and the risks for future pregnancies (recurrence risk about 10 to 15% after a previous postpartum haemorrhage). Plan the next birth (iron optimisation, hospital birth with active management of the third stage, tranexamic acid).
• Psychological support for post traumatic stress and depression.

Prevention of primary postpartum haemorrhage. Active management of the third stage for all women:

• Oxytocin 10 units intramuscularly within 1 minute of birth of the baby (or 5 units slowly intravenously for caesarean section, followed by 10 units/h infusion for 4 hours).
• Controlled cord traction after signs of separation, and uterine massage after the placenta.
• Delayed cord clamping at 1 to 3 minutes.
• Misoprostol 600 microgram orally when oxytocin is not available.
• Tranexamic acid 1 g intravenously at caesarean section in high risk women.

Special groups.

• Women declining blood: iron, erythropoietin, cell salvage, early tranexamic acid, and early surgical intervention.
• Women with bleeding disorders: desmopressin 0.3 microgram/kg or von Willebrand factor concentrate with haematology advice.
• Women with cardiac disease: avoid ergometrine and oxytocin boluses.
• Women with asthma: avoid carboprost.
• Women with pre eclampsia: avoid ergometrine and use fluids cautiously.
• Region specific: home births need active third stage management with oxytocin and misoprostol, community use of tranexamic acid, and rapid referral.

Monitoring. Blood pressure, pulse, respiratory rate, saturation and urine output every 15 minutes until stable, then hourly for 4 hours and every 4 hours for 24 hours. Fundal height and tone, lochia, haemoglobin, clotting and fibrinogen every 1 to 4 hours during active bleeding and at 12 and 24 hours. Temperature every 4 hours. Balloon output.

Referral and escalation. Escalate to the consultant obstetrician and anaesthetist for blood loss over 1000 mL, or any loss with shock. Refer to critical care or high dependency for massive haemorrhage, coagulopathy, hysterectomy or organ dysfunction. Involve haematology and blood bank early. Refer to interventional radiology when the woman is stable and conservative surgery fails. Refer to haematology for suspected inherited bleeding disorder.

Admission criteria. All primary postpartum haemorrhage over 1000 mL, any haemodynamic change, uterine atony needing more than one drug, secondary bleeding with heavy loss, clots or fever, and suspected retained products.

Women with minor secondary bleeding (a pad every 4 hours or more slowly), stable observations, normal haemoglobin and no fever may be followed at home with ultrasound as needed.

Discharge and follow up. Discharge when bleeding is controlled, haemoglobin is stable, the woman can mobilise, and a follow up plan exists. Review at 1 to 2 weeks and 6 weeks with haemoglobin and ferritin. Arrange pre pregnancy counselling and delivery planning for future pregnancy.

Safety netting. Return at once for bleeding that soaks a pad every hour, clots larger than a golf ball, dizziness, faintness, palpitations, shortness of breath, fever, foul smelling discharge, severe abdominal pain, or any sudden increase in bleeding, up to 12 weeks after birth.