Postpartum Hemorrhage

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).

The purpose of this document is to review the etiology, evaluation, and management of postpartum hemorrhage. Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage. The creation of a patient safety team that works to improve the hospital systems for caring for women at risk for major obstetric hemorrhage can help to identify and manage these situations and save lives. Development of clinical pathways, guidelines and protocols designed to provide early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations are essential. A multidisciplinary patient safety team that includes individuals from the Division of Obstetric Anesthesiology, Maternal Fetal Medicine, Neonatology, and the Blood Bank as well as Departments of Nursing, Communication, and Administration and quarterly mock drills of rapid response team, helps to respond to these situations effectively.

Postpartum Hemorrage from Vaginal Delivery Checklist: (view/download pdf document)

Postpartum hemorrhage (PPH) is defined as a blood loss of more than 500 ml after vaginal delivery and more than 1,000 ml after cesarean delivery. The American College of Obstetricians and Gynecologists (ACOG) defines it as a decrease in hematocrit of more than 10% from before to after delivery. Massive uncontrolled hemorrhage after childbirth is the leading cause of pregnancy-related death in the United States and developing countries both. Moreover, obstetric hemorrhage can cause shock, renal failure, and Sheehan's syndrome (postpartum pituitary necrosis). Uterine atony, degrees of retained placenta - including placenta accrete and its variants and genital tract lacerations account for most cases of postpartum hemorrhage. Hemorrhage after the first 24 hours is designated late postpartum hemorrhage.

Although PPH cannot always be anticipated, the cornerstones of effective treatment remain rapid diagnosis and intervention. Our goal here is to review new interventions, and revisit old ones that can assist in controlling acute hemorrhage.

Predisposing Factors:

  1. Bleeding from Placental-site
    • Uterine Atony
    • Some General Anesthetics- halogenated hydrocarbons
    • Over distended uterus - large fetus, twins, hydramnios
    • Following prolonged labor
    • Following very rapid delivery
    • Following oxytocin induced or augmented labor
    • High parity
    • Uterine atony in previous pregnancy
    • Chorioamnionitis
    • Retained placental tissue
    • Abnormally adherent placenta - accrete, increta, percreta
  2. Trauma to the Genital Tract
    • Large episiotomy, including extensions
    • Lacerations of perineum, vagina, or cervix
    • Ruptured uterus
  3. Coagulation Defects

Clinical Characteristics:

Postpartum hemorrhage before placental delivery is called third-stage hemorrhage. Whether bleeding begins before or after placental delivery, or at both times, there may be no sudden massive hemorrhage but rather steady bleeding that at any given instant appears to be moderate, but persists until serious hypovolemia develops. Especially with hemorrhage after placental delivery, the constant seepage may lead to enormous blood loss. The effects of hemorrhage depend to a considerable degree upon the non-pregnant blood volume, magnitude of pregnancy induced hypervolemia, and degree of anemia at the time of delivery. A treacherous feature of postpartum hemorrhage is the failure of the pulse and blood pressure to undergo more than moderate alterations until large amounts of blood have been lost. Sometimes the hypovolemia may not be recognized until very late. When excessive hemorrhage is even suspected in the woman with severe pregnancy-induced hypertension, efforts should be made immediately to identify those clinical and laboratory findings that would prompt vigorous crystalloid and blood replacement.

The differentiation between bleeding from uterine atony and from lacerations is tentatively made on the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most probably is from lacerations. Bright red blood also suggests lacerations. To ascertain the role of lacerations as a cause of bleeding, careful inspection of the vagina, cervix and uterus is essential. Sometimes bleeding may be caused by both atony and trauma, especially after major operative delivery. Anesthesia should be adequate to prevent discomfort during such an examination.

Management of Third-Stage Bleeding:

Some bleeding is inevitable during the third-stage as the result of transient partial separation of the placenta. If the signs of placental separation have appeared, expression of the placenta should be attempted by manual fundal pressure. Descent of placenta is indicated by the cord becoming slack. If bleeding continues, manual removal of the placenta is mandatory.

Technique of Manual Removal: adequate analgesia and anesthesia is mandatory. Aseptic surgical technique should be employed. After grasping the fundus through the abdominal wall with one hand, the other hand is introduced into the vagina and passed into the uterus, along the umbilical cord. As soon as the placenta is reached, its margin is located and the ulnar border of the hand insinuated between it and the uterine wall. Then with the back of the hand in contact with the uterus, the placenta is peeled off its uterine attachment by a motion similar to that employed in separating the leaves of a book. After its complete separation, the placenta should be grasped with the entire hand, which is then gradually withdrawn. Membranes are removed at the same time by carefully teasing them from the deciduas, using ring forceps to grasp them as necessary. Some clinicians prefer to wipe out the uterine cavity with a sponge. If this is done, it is imperative that the sponge not be left in the uterus or vagina. (Source-21st edition William's Obstetrics)

Management After Delivery of Placenta:

The fundus should always be palpated following placental delivery to make certain that the uterus is well contracted. If not firm vigorous fundal massage is indicated. Most often 20 U of oxytocin in 1000 ml of lactated Ringer or normal saline proves effective when administered intravenously at approximately 10 ml/minute (200 mU of oxytocin per minute) simultaneously with effective uterine massage. Oxytocin should never be given as an undiluted bolus dose as serious hypotension or cardiac arrhythmias may follow.

Bleeding Unresponsive to Oxytocics: continued bleeding after multiple oxytocic administrations may be from unrecognized genital tract lacerations, including in some cases of uterine rupture. The following management is suggested to be initiated immediately:

  1. Employ bimanual uterine compression. The technique consists simply of massage of the posterior aspect of the uterus with the abdominal hand and massage through the vagina of the anterior uterine aspect with the other fist. This procedure will control most hemorrhage.
  2. Obtain help!
  3. Blood transfusions (if needed). The rate of blood transfusion during cesarean section ranges from 1% to 14%. Intraoperative blood salvage (IBS) is an alternative to homologous blood transfusion and its attendant risks of infection and transfusion reaction. But the use of cell saver technology during cesarean section, intraoperative erythrocyte salvage and autotransfusion, has been limited by theoretical concerns about amniotic fluid embolism and infection. IBS may be lifesaving in remote regions with limited blood banking services. Women at risk for intraoperative hemorrhage (previa, known accreta, preoperative anemia) who object to homologous blood transfusion may benefit from IBS technology. Blood is collected, after the delivery of infant and removal of all fetal products and amniotic fluid, with a large bore suction device. The cell saver device with leukocyte depletion filter, then washes and filters the suctioned fluid and collected red cells can be transfused. This process can be set up in a single, continuous circuit so that patients with religious objections (e.g. Jehovah's Witnesses) may accept therapy with this device.
  4. Explore the uterine cavity manually for retained placental fragments or lacerations. If a portion of placenta is missing, the uterus should be explored and the fragment is removed either manually or by curettage.
  5. Thoroughly inspect the cervix and vagina after adequate exposure. If any laceration is seen, it should be sutured to control the bleeding.
  6. Prostaglandins: the 15-methyl derivatives of prostaglandin F2alpha was approved in the mid 1980s by the Food and Drug Administration for treatment of uterine atony. The initial recommended dose is 250 micro-g (0.25 mg) given intramuscularly, and this is repeated if necessary at 15 to 90 minute intervals up to a maximum of eight doses. Prostaglandin E1 analogue, misoprostol is best known for the labor induction and medical abortion is quite effective to treat uterine atony. Rectally or orally doses of 400 to 1000 micro-g is given and it is rapidly absorbed. It is also safe for preeclamptic and hypertensive patients, having no effect on blood pressure. Misoprostol is not associated with MI and bronchospasm and therefore it is safe for asthmatic patients. The drug's other significant advantages are its heat-stable preparation (it requires no refrigeration) and its low cost.
  7. Uterine packing: concerns of concealed hemorrhage and uterine over distension has made the use of this procedure very rare. In recent years, however, several modifications of this procedure have allayed these concerns. Balloon tamponade using either a Foley catheter (30 ml balloon) or a Sengstaken-Blakemore tube has been shown to effectively control postpartum bleeding, and may be useful in several settings: uterine atony, retained placental tissue and placenta accreta. The Foley catheter or Sengstaken-Blakemore tube should be guided through the cervix into the uterus and the balloon can then be inflated to achieve the desired tamponade and can be removed in 12 to 24 hours.
  8. Surgical management: if retained placental fragments are suspected, curettage is done to control the bleeding. In cases of uterine rupture patient might need repair of laceration or hysterectomy. The most common cause of uterine rupture is separation of a previous cesarean scar. Uterine atony if not under control by any procedure might sometimes need hysterectomy or internal iliac artery ligation.
  9. Angiographic embolization: this technique has become popular for the management of intractable puerperal hematomas. In can be used primarily or usually when hemostasis is not obtained by surgical methods.

Medical Management of Postpartum Hemorrhage (Source: ACOG Practice Bulletin No. 76, October 2006)





Oxytocin (Pitocin)

IV: 10-40 units in 1 liter normal saline or lactated Ringer's solution.
IM: 10 units


Avoid undiluted rapid IV infusion, which causes hypotension.

Methylergonovine (Methergine)

IM: 0.2 mg

Every 2-4 hour

Avoid if patient is hypertensive.

15-methyl PGF (Carboprost)

IM: 0.25 mg

Every 15-90 min,
8 doses maximum

Avoid in asthmatic patients; relative contraindication if hepatic, renal and cardiac disease. Diarrhea, fever, tachycardia can occur.

(Prostin E2)

Suppository: vaginal or rectal; 20 mg

Every 2 hour

Avoid if patient is hypotensive. Fever is common. Stored frozen, it must be thawed to room temperature.

(Cytotec, PGE1)

800-1,000 mcg rectally


Can cause nausea and vomiting.

Abbreviations: IV, intravenously; IM, intramuscularly; PG, prostaglandin.

Inversion of the uterus:

Complete uterine inversion after delivery of the infant is almost always the consequence of strong traction on an umbilical cord attached to a placenta implanted in the fundus. Incomplete uterine inversion may also occur. Uterine inversion is most often associated with immediate life-threatening hemorrhage, and without prompt treatment it may be fatal. Delay in treatment increases the mortality rate appreciably. It is imperative that a number of steps be taken immediately and simultaneously:

  1. Assistance, including an anesthesiologist is called immediately. Preferably two intravenous infusions lines are made operational for fluids and blood transfusion if needed.
  2. The freshly inverted uterus with placenta already separated from it may often be replaced simply by immediately pushing up on the fundus with the palm of the hand and fingers in the direction of the long axis of vagina.
  3. If placenta is still attached, it is not removed until the infusion systems are in place and anesthesia is given. After removing the placenta, the palm of the hand is placed on the center of the fundus with the fingers extended to identify the margins of the cervix. Pressure is then applied with the hand so as to push the fundus upward through the cervix.
  4. As soon as the uterus is restored to its normal configuration, the agent used to provide relaxation is stopped and simultaneously oxytocin is started to contract the uterus while the operator maintains the fundus in normal position.
  5. Initially, bimanual compression will aid control of further hemorrhage until uterine tone is recovered. After the uterus is well contracted, the operator continues to monitor the uterus transvaginally for any evidence of subsequent inversion.
  6. Surgical Intervention: most of the time the inverted uterus can be replaced to its normal position by the techniques described above. If the uterus cannot be reinverted by vaginal manipulation because of a dense constriction ring, laparotomy in imperative. The fundus is then may be simultaneously pushed upward from below and pulled from above. A traction suture well placed in the inverted fundus may be of aid. If the constriction ring still prohibits reposition, it is carefully incised posteriorly to expose the fundus. This surgical technique was first described by Van Vugt and associates in 1981. After replacement of the fundus, the anesthetic agent which is used to relax the myometrium is stopped, oxytocin infusion is started and the uterine incision is repaired.

Long-term effects of PPH:

Often, the consequences of PPH are more severe because of baseline maternal anemia. High doses of iron may be needed and injectable iron preparations are generally quite effective. Erythropoietin (EPO) is a hormone secreted by the kidney that regulates the differentiation and maturation of erythrocytes. In the normal pregnancy, EPO levels rise to two to four times that seen in nonpregnant, nonanemic controls and peak in the third trimester. Use of recombinant human erythropoietin (rHuEPO) during pregnancy has been reported in women with severe anemia due to renal failure, thalassemia, leukemia, and iron-deficiency anemia. RHuEPO is useful in: (1) antepartum management of the severely anemic patient at risk for hemorrhage, (2) antepartum management of the nonanemic woman at risk for hemorrhage to allow for autologous blood transfusion, (3) the postpartum augmentation of anemia due to hemorrhage. All patients on rHuEPO therapy require iron supplementation.

Sheehan Syndrome: severe intrapartum or early postpartum hemorrhage is on rare occasions followed by pituitary failure. The classical case of Sheehan syndrome is characterized by failure of lactation, amenorrhoea, breast atrophy, loss of pubic and axillary hair, hypothyroidism, and adrenal cortical insufficiency. Lactation after delivery usually, but not always, excludes extensive pituitary necrosis. The incidence of Sheehan syndrome was originally estimated to be 1 per 10,000 deliveries, and it appears to be even rarer today in the United States. Application of the tests of hypothalamic and pituitary function now available should identify milder forms of the syndrome and define their prevalence. The anterior pituitary of some women who develop hypopituitarism after puerperal hemorrhage does respond to various releasing hormones, which at the least implies impaired hypothalamic function.


We have described a variety of novel techniques, in addition to our traditional approach, that can be highly successful in managing PPH. Depending on the availability of resources (anesthesia, interventional radiology, cost) most of these approaches can be incorporated into routine practice with little hardship in the majority of modern obstetrical suites. Introducing these techniques can help to lower maternal death rates, minimize hysterectomies and blood transfusions, and improve patient satisfaction.

Suggested Reading:

  1. World Health Organization
    WHO Recommendations for the Prevention of Postpartum Hemorrhage
  2. National Institutes of Health (NIH)
    Focus on NICHD International Health Activity (Part 2)
  3. USAID - Maternal and Child Health
    Preventing Postpartum Hemorrhage

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