Merck Manual

Please confirm that you are not located inside the Russian Federation

Loading

Excessive Uterine Bleeding at Delivery

(Postpartum Hemorrhage)

By

Julie S. Moldenhauer

, MD, Children's Hospital of Philadelphia

Last full review/revision Jan 2020| Content last modified Jan 2020
Click here for the Professional Version
GET THE QUICK FACTS
NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version

Excessive bleeding from the uterus refers to loss of more than 2 pints of blood or symptoms of significant blood loss that occur within 24 hours of 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.

Blood loss is considered excessive if one of the following occurs within 24 hours of delivery:

  • More than 2 pints of blood are lost.

  • The woman has symptoms of significant blood loss, such as low blood pressure, a rapid heart rate, dizziness, light-headedness, fatigue, and weakness.

Excessive blood loss usually occurs soon after delivery but may occur as late as 1 month afterward.

Causes

The most common cause of excessive bleeding at delivery is

  • A uterus that does not start contracting after delivery but instead remains loose and stretched out (a condition called uterine atony)

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:

Excessive bleeding can also result when the following occurs:

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

Diagnosis

  • A doctor's evaluation

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 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.

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 or a bleeding disorder). These conditions are treated if possible.

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. Doctors usually give the woman oxytocin through an intravenous line or inject it into a muscle. This drug helps the uterus contract. Oxytocin helps reduce blood loss.

When the placenta is delivered, doctors check it to determine whether it is complete. If it is incomplete, fragments that remain in the uterus (which can cause bleeding) are removed by hand.

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

  • Massage of the uterus

  • Drugs to help the uterus contract

  • Fluids given by vein (intravenously)

  • Sometimes a blood transfusion

  • Sometimes a procedure to compress the arteries to the uterus

If excessive bleeding occurs, the woman's uterus is massaged by pressing on 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, another drug that helps the uterus contract is also given. These drugs 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:

  • A balloon may be inserted into the uterus and inflated.

  • Packing may be inserted into the uterus

  • A doctor may place stitches (sutures) around the bottom of the uterus—a procedure that requires abdominal surgery.

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.

Drugs Mentioned In This Article

Generic Name Select Brand Names
PITOCIN
NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
Others also read

Also of Interest

Videos

View All
The Uterus, Cervix, and Cervical Canal
Video
The Uterus, Cervix, and Cervical Canal
3D Models
View All
Contents of the Female Pelvis
3D Model
Contents of the Female Pelvis

SOCIAL MEDIA

TOP