Excessive Uterine Bleeding at Delivery
Excessive bleeding from the uterus refers to loss of more than about 1 pint of blood during or 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 during and 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 pregnancy.
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.
The most common cause of excessive bleeding at delivery is
When the uterus does not start contracting after delivery, 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 labor was prolonged, abnormal, or rapid
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 a piece of the placenta remains inside the uterus after delivery
Excessive bleeding after one delivery may increase the risk of excessive bleeding after subsequent deliveries. Fibroids in the uterus may also increase the risk.
The diagnosis of postpartum hemorrhage is based on close observation of the amount of bleeding. The vagina and perineum are examined to check for tears that may need to be repaired. Doctors gently press on the woman's abdomen to feel the uterus and determine whether that it is firm. A soft uterus may mean that the uterus is not contracting as it should and blood is collecting inside the uterus.
Monitoring the woman's vital signs, such as blood pressure and heart rate, can help doctors determine whether blood loss is excessive. A drop in blood pressure or a rapid heart rate may indicate excessive bleeding.
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 or a bleeding disorder). 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.
If excessive bleeding occurs, the woman's uterus is massaged by pressing on the her abdomen, and she is given oxytocin continuously through an intravenous line. These measures help the uterus contract. The woman is also given fluids intravenously to help restore the amount of fluid in the bloodstream. 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. Rarely, dilation and curettage is needed 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). 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. Procedures that may be used include the following:
The procedures used usually do not cause infertility, abnormalities in menstruation, or other lasting problems.
Sometimes the arteries supplying blood to the uterus must be blocked surgically or by inserting material through catheters into the arteries.
Removal of the uterus (hysterectomy) is rarely necessary to stop the bleeding.
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