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Excessive Uterine Bleeding After Delivery

(Postpartum Hemorrhage)

by Julie S. Moldenhauer, MD

Excessive bleeding from the uterus (postpartum hemorrhage) refers to loss of more than about 1 pint of blood immediately after vaginal delivery of a baby or loss of more than about 2 pints after cesarean delivery.

After the baby is delivered, excessive bleeding from the uterus is a major concern. Ordinarily, the woman loses about 1 pint of blood after vaginal delivery. Blood is lost because some blood vessels are opened when the placenta detaches from the uterus. The contractions of the uterus help close these vessels until the vessels can heal. Typically, cesarean delivery results in about twice the blood loss as vaginal delivery, partly because delivery requires an incision in the uterus, and a lot of blood is pumped to the uterus during labor.

In vaginal deliveries, loss of more than about 1 pint of blood during or after the third stage of labor (when the placenta is delivered) is considered excessive. In cesarean deliveries, loss of more than about 2 pints is considered excessive. Excessive blood loss usually occurs soon after delivery but may occur as late as 1 month afterward.

Excessive bleeding may result when the contractions of the uterus after delivery are impaired. Then, the blood vessels that were opened when the placenta detached continue to bleed. Contractions may be impaired in the following situations:

  • When the uterus has been stretched too much—for example, by too much amniotic fluid in the uterus, by several fetuses, or by a very large fetus

  • When a piece of placenta remains inside the uterus after delivery

  • When labor was prolonged or abnormal

  • When a woman has delivered more than five babies

  • When a muscle-relaxing anesthetic was used during labor and delivery

Excessive bleeding can also result when the following occurs:

  • When the vagina or cervix is torn or cut during delivery

  • When a woman has a bleeding disorder that interferes with clotting

  • When the tissues around the fetus are infected (called chorioamnionitis), leading to infection of the uterus (called endometritis)

  • Rarely, when the uterus ruptures or is turned inside out (inverted)

Excessive bleeding after one delivery may increase the risk of excessive bleeding after subsequent deliveries. Fibroids in the uterus may also increase the risk.

Prevention

Before a woman goes into labor, doctors take steps to prevent or to prepare for excessive bleeding after delivery. For example, they determine whether the woman has any conditions that increase the risk of bleeding (such as too much amniotic fluid). If the woman has an unusual blood type, doctors make sure that her blood type is available. Delivery should be slow and as gentle as possible.

After delivery of the placenta, the woman is monitored for at least 1 hour to make sure that the uterus has contracted and to assess bleeding.

Treatment

If severe bleeding occurs, the woman’s lower abdomen is massaged, and she is given oxytocin continuously through an intravenous line. These measures help the uterus contract. If bleeding continues, drugs that help the uterus contract can be injected into a muscle, placed as a tablet in the rectum, or, during cesarean delivery, injected into the uterus. The woman may need a blood transfusion.

Doctors look for the cause of excessive bleeding. The uterus may be examined to see whether any fragments of the placenta remain. Dilation and curettage may be done to remove these fragments. In this procedure, a small, sharp instrument (curet) is passed through the cervix (which is usually still open from the delivery—see see Diagnostic Procedures : Dilation and Curettage). The curet is used to remove the retained fragments. This procedure requires an anesthetic. The cervix and vagina are examined for tears.

If the uterus cannot be stimulated to contract and bleeding continues, the arteries supplying blood to the uterus may have to be compressed to stop blood flow. For example, a balloon may be inserted into the uterus and inflated, packing may be inserted into the uterus, or a doctor may place stitches (sutures) around the bottom of the uterus. The procedures used usually do not cause infertility, abnormalities in menstruation, or other lasting problems. Removal of the uterus (hysterectomy) is rarely necessary to stop the bleeding.

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  • PITOCIN