Postpartum Hemorrhage in Emergency Medicine
- Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE more...
Defining postpartum hemorrhage (PPH) has historically been difficult. Waiting for a patient to meet PPH criteria, particularly in resource-poor settings or in cases of sudden hemorrhage, may delay appropriate intervention. Any bleeding that has the potential to result in hemodynamic instability, if left untreated, should be considered PPH and managed accordingly. PPH can be divided into 2 types: early (< 24 hours after delivery) and late (24 hours to 6 weeks after delivery). Most cases of PPH (>99%) are early.
Signs and symptoms
The clinical history should begin with consideration of signs and symptoms that are most crucial in managing potential circulatory collapse, identifying the cause of PPH, and selecting therapies, as follows.
Severity of bleeding:
Is the placenta delivered?
What has been the duration of the third stage of labor?
How long has the bleeding been heavy?
Was initial postdelivery bleeding light, medium, or heavy?
Are symptoms of hypovolemia present?
In delayed PPH, what is the bleeding pattern since delivery?
Is there a history of transfusion or transfusion reaction? What was the reason for transfusion?
Past medical history
Predisposing factors and potential etiology:
History of PPH
Gravity, parity, length of most recent pregnancy, history of multiple gestations
Number of fetuses for the most recent pregnancy
Spontaneous versus manual delivery of the placenta
Vaginal delivery versus cesarean delivery, current and past
Cesarean delivery – Planned in advance, decided on after a failed vaginal delivery attempt, or performed on an emergency basis
Other uterine surgeries
Personal or family history of bleeding disorder
Vaginal penetration since delivery
Signs or symptoms of infection
Other information helpful for continued management
Time and location of delivery, and any assistant(s) involved
Location and provider of prenatal care
Health of infant at delivery and any complications or concerns before, during, or after delivery
Past surgical history
The physical examination should focus on determining the cause of the bleeding. Important organ systems to assess include the following:
Pulmonary (pulmonary edema)
Cardiovascular (heart murmur, tachycardia, strength of peripheral pulses)
Neurologic (mental status changes from hypovolemia)
Specifically, examination should include the following:
Speculum examination of the cervix and vagina
See Presentation for more detail.
Laboratory studies that may be helpful include the following:
Complete blood count (CBC) with hemoglobin and hematocrit
Blood urea nitrogen (BUN) and creatinine
Type and crossmatch
Liver function tests (LFTs), amylase, lipase
Imaging studies to be considered include the following:
Ultrasonography – This is a fast and helpful modality for imaging pelvic structures and should be the first-line study for pelvic pathology
Computed tomography (CT) – This may be a helpful follow-up study when ultrasonography is not diagnostic and may also be the first-line study when a pelvic hematoma or abscess is suspected
Magnetic resonance imaging (MRI) – This study can help determine whether a fluid collection (hematoma or abscess) is intrauterine or extrauterine when ultrasonography or CT does not; it can also help to distinguish a placenta accreta from simple retained products of conception
See Workup for more detail.
Prehospital care includes the following:
Primary survey of the mother (vital signs, ABCs)
Immediate interventions as appropriate – Gentle massage of the uterine fundus; fluid resuscitation with crystalloids; packing of any visible perineal lacerations; oxytocin
Minimal measure necessary on scene to stabilize the mother and baby for transport and further care
Emergency department care includes the following:
History and physical examination according to acute life support algorithms
Immediate OB/GYN consultation
Primary survey (ABCs)
Laboratory studies (including blood cultures if the patient is febrile or the vaginal blood/discharge is malodorous)
Secondary survey – Focused physical examination; bedside ultrasonography (FAST)
Interventions to address specific presentations as appropriate – Uterine atony; uterine rupture; trauma; retained placental tissue; uterine inversion; thrombosis
Immediate consultation with an OB/GYN is vital. If no OB/GYN is available, a general surgeon should be consulted. Direct contact with the blood bank is essential for assuring timely arrival of any blood products ordered.
Defining postpartum hemorrhage (PPH) is problematic and has been historically difficult. Waiting for a patient to meet the postpartum hemorrhage criteria, particularly in resource-poor settings or with sudden hemorrhage, may delay appropriate intervention. Postpartum hemorrhage is traditionally defined as blood loss greater than 500 mL during a vaginal delivery or greater than 1,000 mL with a cesarean delivery. However, significant blood loss can be well tolerated by most young healthy females, and an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition.
The addition of "a 10% drop in hemoglobin" to the definition provides an objective laboratory measure. However, this is not helpful in acute situations since it can take hours for losses to create laboratory changes in red blood cell measurements. Signs and symptoms of hypovolemia (lightheadedness, tachycardia, syncope, fatigue and oliguria) are also of limited utility as they can be late findings in a young and otherwise healthy female. As a result, any bleeding that has the potential to result in hemodynamic instability, if left untreated, should be considered postpartum hemorrhage and managed accordingly.
Postpartum hemorrhage can be divided into 2 types: early postpartum hemorrhage, which occurs within 24 hours of delivery, and late postpartum hemorrhage, which occurs 24 hours to 6 weeks after delivery. Most cases of postpartum hemorrhage, greater than 99%, are early postpartum hemorrhage. Notably, most women are still under the care of their delivering provider during this time. With many women delivering outside of hospitals and early postpartum hospital discharge being a growing trend, postpartum hemorrhage that presents to the emergency department may be either early or late.
Within this combined population, emergency medicine providers are likely to receive patients that fall into 1 of 3 categories:
Those that are too close to delivery to be transferred to another location (the facility's labor and delivery suite or to another facility)
Women who delivered at home, at a nonhospital facility, or en route to the hospital and are too hemodynamically unstable to be transferred to a labor and delivery floor within the facility or at another location
Patients who were discharged home after delivery in stable condition, but had concerning bleeding that prompted an emergency department visit
At term, the uterus and placenta receive 500-800 mL of blood per minute through their low resistance network of vessels. This high flow predisposes a gravid uterus to significant bleeding if not well physiologically or medically controlled. By the third trimester, maternal blood volume increases by 50%, which increases the body's tolerance of blood loss during delivery.
Following delivery of the fetus, the gravid uterus is able to contract down significantly given the reduction in volume. This allows the placenta to separate from the uterine interface, exposing maternal blood vessels that interface with the placental surface. After separation and delivery of the placenta, the uterus initiates a process of contraction and retraction, shortening its fiber and kinking the supplying blood vessels, like physiologic sutures or "living ligatures."
If the uterus fails to contract, or the placenta fails to separate or deliver, then significant hemorrhage may ensue. Uterine atony, or diminished myometrial contractility, accounts for 80% of postpartum hemorrhage. The other major causes include abnormal placental attachment or retained placental tissue, laceration of tissues or blood vessels in the pelvis and genital tract, and maternal coagulopathies. An additional, though uncommon, cause is inversion of the uterus during placental delivery.
The traditional pneumonic "4Ts: tone, tissue, trauma, and thrombosis" can be used to remember the potential causes. Here, a 5th is added; “T” for uterine inversion that will be called “traction.”
The incidence of postpartum hemorrhage is about 1 in 5 pregnancies, but this figure varies widely due to differential definitions for postpartum hemorrhage.
The prognosis depends on the cause of the PPH, its duration, the amount of blood loss, comorbid conditions, and the effectiveness of treatment. Prompt diagnosis and treatment are essential to achieving the best outcome for any given patient. Most reproductive-age women will do well if managed promptly in a setting with operative and blood-product resources available.
Consequences include the sequelae of hemorrhage; aggressive fluid resuscitation; blood-product exposure; and procedures done to control uterine, cervical, vaginal, or peritoneal hemorrhage.
Although accountable for only 8% of maternal deaths in developed countries, postpartum hemorrhage is the second leading single cause of maternal mortality, ranking behind preeclampsia/eclampsia. Globally, postpartum hemorrhage is the leading cause of maternal mortality. The condition is responsible for 25% of delivery-associated deaths, and this figure is as high as 60% in some countries. International initiatives to improve outcomes have invested in training birth attendants (traditional or otherwise) and nurse midwives on the active management of the third stage of labor (the period immediately after delivering of the infant). Most efforts focus on uterine atony, which is the primary cause of postpartum hemorrhage. This has included education on manual techniques to increase uterine contraction-retraction and making pharmacologic uterotonic agents (oxytocin and misoprostol) more available.[3, 4, 5]
Postpartum hemorrhage is a potentially life-threatening complication of both vaginal and cesarean delivery. Associated morbidity is related to the direct consequences of blood loss as well as the potential complications of hemostatic and resuscitative interventions.
Consequences of uncontrolled hemorrhage
Hypovolemic shock and associated organ failure including renal failure, stroke, myocardial infarction may occur.
Postpartum hypopituitarism (Sheehan syndrome) may occur. Acute blood loss and/or hypovolemic shock during and after childbirth can lead to hypoperfusion of the pituitary and subsequent necrosis. Although often asymptomatic, it may present with an inability to breastfeed, fatigue, hypogonadism, amenorrhea, and hypotension.
Death secondary to hypovolemic shock may occur.
Consequences of fluid resuscitation
Fluid overload can lead to extremity edema and pulmonary edema. The latter is less common in young healthy women, but it should be suspected in the setting of large fluid and blood product resuscitation.
Dilutional coagulopathy occurs when crystalloids and/or serum-poor blood products are given in large volume.
Risks from exposure to blood products
The following may develop as a result of exposure of blood products:
Allergic or febrile reactions have an incidence of about 1 case per 333 population. 
Anaphylactic reactions occur in 1 in 20,000 to 1 in 47,000 blood products transfused. 
Transfusion-related acute lung injury (TRALI) occurs in 1 out of every 5,000 transfusions, but more often with high plasma containing products like fresh frozen plasma (FFP) and platelets. It often starts within 1-2 hours of the transfusion, but it can happen anytime up to 6 hours after a transfusion. The symptom complex includes severe bilateral pulmonary edema, severe hypoxemia, tachycardia, cyanosis, hypotension, and fever. 
Acute immune hemolytic reaction, though rare, is the most serious type of transfusion reaction. Symptoms are associated with red blood cell hemolysis. Patients may have fevers, chills, chest and lower back pain, nausea, renal failure, and death if the transfusion is not stopped.
Delayed hemolytic reaction: This type of reaction happens when the body slowly attacks antigens (other than ABO antigens) on the transfused blood cells. Symptoms occur days to weeks after a transfusion. Affected patients are either asymptomatic or have mild symptoms, which may include jaundice, low-grade fever, and a low hemoglobin or hematocrit. 
Infection: Hepatitis is the most common disease transmitted by blood transfusions. According to the American Red Cross, about 1 blood transfusion in 205,000 transmits a hepatitis B infection, and 1 blood transfusion in about 2 million transmits hepatitis C. Other rare but potential infections include HIV (risk of 1 in 2.5 million), Lyme disease, babesiosis, and malaria. Donors are screened for potential exposure so transmission is very rare. Rarely, blood may be contaminated with tiny amounts of skin bacteria during donation. Platelets are the most likely blood product to be affected by contamination from skin flora.
Metabolic reactions: With large volume and rapid transfusions, patients are at risk of encountering 3 metabolic reactions: hypothermia, hyperkalemia, and citrate toxicity. Hypothermia results from the transfusion of unwarmed crystalloid or colloid that drops the body temperature. Hypothermia inhibits coagulation and can worsen postpartum hemorrhage. Citrate is a blood product additive that binds serum calcium and can cause hypocalcemia with large-volume transfusions. Hemolysis occurs with red blood cell storage releasing increasing amounts of intracellular potassium with time. Transfusions of older red blood cells increase the risk of hyperkalemia.
Risks associated with surgical intervention
The following may result following surgical intervention:
Intubation and anesthesia complications: Pregnant women have an increased risk for aspiration, failed intubation, and death from failed ventilation when compared with nonpregnant patients. Respiratory injury or infection, myocardial infarction, myocardial arrhythmia, stroke, or allergic reactions to anesthetic medications may also rarely occur.
Bleeding: Continued bleeding from the genital tract or a bleeding complication from the surgery may occur.
Infection: Sepsis, wound infection, or pneumonia is possible.
Need for permanent sterilization to control bleeding
If the bleeding cannot be controlled conservatively (removal of products of conception, suturing disrupted tissues, application of pressure) then surgical intervention may be necessary. In severe cases, the following may occur:
Asherman syndrome, which is secondary (non-hormone mediated) amenorrhea due to uterine scarring that develops after infection and/or curettage performed to remove placental fragments
Postpartum hemorrhage can be a frightening experience for patients. It is important to provide reassurance and communicate through each step of emergency care. Make patients aware of what to anticipate through their clinical course including expected procedures; transport; and the indication, risks, and benefits of interventions.
Minino AM, Heron MP, Murphy SL, et al. National Vital Statistic Reports: Deaths 2004. US Department of Health and Human Services and the Centers for Disease Control and Prevention. August 21, 2007. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf.
World Health Organization. World Health Report 2005: Make Every Mother and Child Count. Available at http://www.who.int/whr/2005/whr2005_en.pdf. Accessed: September 10, 2008.
USAID (United States Agency for International Development). Postpartum Hemorrhage Prevention. USAID Postpartum Hemorrhage Prevention Initiative (POPPHI). Available at http://www.pphprevention.org/briefs_newsletters.php. Accessed: September 9, 2008.
PATH. Saving Mother's Lives: Initiative promotes proven strategy for preventing postpartum hemorrhage. PATH: Preventing Postpartum Hemorrhage. Available at http://www.path.org/projects/preventing_postpartum_hemorrhage.php. Accessed: September 9, 2008.
Miller S, Lester F, Hensleigh P. Prevention and treatment of postpartum hemorrhage: new advances for low-resource settings. J Midwifery Womens Health. 2004 Jul-Aug. 49(4):283-92. [Medline]. [Full Text].
Menitove JE, McElligott MC, Aster RH. Febrile transfusion reaction: what blood component should be given next?. Vox Sang. 1982. 42(6):318-21. [Medline].
Shimada E, Tadokoro K, Watanabe Y, et al. Anaphylactic transfusion reactions in haptoglobin-deficient patients with IgE and IgG haptoglobin antibodies. Transfusion. 2002 Jun. 42(6):766-73. [Medline].
Popovsky MA. Transfusion and lung Injury. Transfusion Clin Biol. 2001. 8:272-7.
Kicklighter EJ, Klein HG. Hemolytic transfusion reactions. Linden JV, Bianco C, eds. Blood Safety and Surveillance. New York: Marcel Dekker; 2001. 47-70.
Tintinalli JE, Kelen GD, Stapczynski JS. Gynecology and Obstetrics: Post Partum Hemorrhage. Emergency Medicine: A Comprehensive Study Guide. 6th. New York: McGraw Hill; 2004. 682.
Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2014 Feb 13. 2:CD003249. [Medline].
Sentilhes L, Lasocki S, Ducloy-Bouthors AS, et al. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Br J Anaesth. 2015 Apr. 114 (4):576-87. [Medline].
Ducloy-Bouthors AS, Jude B, Duhamel A, et al, for the EXADELI Study Group. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011. 15 (2):R117. [Medline].
Fox S. Preparing for ob/gyn emergencies: ACOG issues tips. February 20, 2014. Available at http://www.medscape.com/viewarticle/820913. Accessed: February 25, 2014.
Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014 Mar. 123(3):722-5. [Medline].
Soriano D, Dulitzki M, Schiff E, Barkai G, Mashiach S, Seidman DS. A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol. 1996 Nov. 103(11):1068-73. [Medline].
Winikoff B, Dabash R, Durocher J, Darwish E, Nguyen TN, Leon W, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet. 2010 Jan 16. 375(9710):210-6. [Medline].
Martin E, Legendre G, Bouet PE, Cheve MT, Multon O, Sentilhes L. Maternal outcomes after uterine balloon tamponade for postpartum hemorrhage. Acta Obstet Gynecol Scand. 2015 Apr. 94 (4):399-404. [Medline].
Howard TF, Grobman WA. The relationship between timing of postpartum hemorrhage interventions and adverse outcomes. Am J Obstet Gynecol. 2015 Aug. 213 (2):239.e1-3. [Medline].
Sparrow AH, Schwemmer SS, Thompson KH. Radiosensitivity studies with woody plants. III. Predictions of limits of probable acute and chronic LD50 values from lognormal distributions of interphase chromosome volumes in gymnosperms. Radiat Res. 1976 Feb. 65(2):315-26. [Medline].
[Guideline] American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); (ACOG practice bulletin; no. 76). 2006 Oct. 10 p. [Full Text].
[Guideline] World Health Organization (WHO). WHO recommendations for the prevention of postpartum haemorrhage. Geneva, Switzerland: World Health Organization (WHO). 2007. 116 p. [Full Text].
Baskett TF. Complications of the third stage of labour. Essential Management of Obstetrical Emergencies. 3rd ed. Bristol, England: Clinical Press; 1999. 196-201.
Bobrowski RA, Jones TB. A thrombogenic uterine pack for postpartum hemorrhage. Obstet Gynecol. 1995 May. 85(5 Pt 2):836-7. [Medline].
Boulleret C, Chahid T, Gallot D, et al. Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol. 2004 Jul-Aug. 27(4):344-8. [Medline].
Bouwmeester FW, Jonkhoff AR, Verheijen RH, van Geijn HP. Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII. Obstet Gynecol. 2003 Jun. 101(6):1174-6. [Medline].
Carr PL, Ricciotti HA, Freund K, Kahan S. Postpartum hemorrhage. Ob/gyn and Women's Health: In a Page. Blackwell Publishing; 2003. 132.
Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. 2003 Feb 21. 52(2):1-8. [Medline]. [Full Text].
Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol. 1991 Jan. 77(1):69-76. [Medline].
Cunningham FG, et al. Obstetrical hemorrhage. William's Obstetrics. 21st ed. 2001. 619-669.
Cunningham FG, MacDonald PC, Gant NF, et al. Abnormalities of the third stage of labor. William's Obstetrics. 1993. 615-20.
Dildy GA 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol. 2002 Jun. 45(2):330-44. [Medline].
Druelinger L. Postpartum emergencies. Emerg Med Clin North Am. 1994 Feb. 12(1):219-37. [Medline].
Gilbert WM, Moore TR, Resnik R, Doemeny J, Chin H, Bookstein JJ. Angiographic embolization in the management of hemorrhagic complications of pregnancy. Am J Obstet Gynecol. 1992 Feb. 166(2):493-7. [Medline].
Gilstrap LC 3rd, Ramin SM. Postpartum hemorrhage. Clin Obstet Gynecol. 1994 Dec. 37(4):824-30. [Medline].
Goldberg CC, Kallen MA, McCurdy CM, Miller HS. Effect of intrapartum use of oxytocin on estimated blood loss and hematocrit change at vaginal delivery. Am J Perinatol. 1996 Aug. 13(6):373-6. [Medline].
Hofmeyr GJ, Ferreira S, Nikodem VC, et al. Misoprostol for treating postpartum haemorrhage: a randomized controlled trial [ISRCTN72263357]. BMC Pregnancy Childbirth. 2004 Aug 6. 4(1):16.
Mendelson MH. Postpartum emergencies. Harwood-Nuss AL, ed. The Clinical Practice of Emergency Medicine. 3rd ed. 2000. 331-3.
Michalakes CJ, Pundt MR, Kerryann BB. Obstetrics and disorders of pregnancy. Aghababian RV, ed. Emergency Medicine: The Core Curriculum. 1998. 598-600.
Nordstrom L, Fogelstam K, Fridman G, Larsson A, Rydhstroem H. Routine oxytocin in the third stage of labour: a placebo controlled randomised trial. Br J Obstet Gynaecol. 1997 Jul. 104(7):781-6. [Medline].
O'Brien P, El-Refaey H, Gordon A, Geary M, Rodeck CH. Rectally administered misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a descriptive study. Obstet Gynecol. 1998 Aug. 92(2):212-4. [Medline].
Petrovic O, Zupanic M, Rukavina B, Vlastelic I, Cuk D. Placenta accreta: postpartum diagnosis and a potentially new mode of management using real-time ultrasonography. J Clin Ultrasound. 1994 Mar-Apr. 22(3):204-8. [Medline].
Pierre F, Mesnard L, Body G. For a systematic policy of iv oxytocin inducted placenta deliveries in a unit where a fairly active management of third stage of labour is yet applied: results of a controlled trial. Eur J Obstet Gynecol Reprod Biol. 1992. 43:131-135.
Prendiville WJ. The prevention of post partum haemorrhage: optimising routine management of the third stage of labour. Eur J Obstet Gynecol Reprod Biol. 1996 Oct. 69(1):19-24. [Medline].
Roberts WE. Emergent obstetric management of postpartum hemorrhage. Obstet Gynecol Clin North Am. 1995 Jun. 22(2):283-302. [Medline].
Sherer DM, Abulafia O, Anyaegbunam AM. Intra- and early postpartum ultrasonography: a review. Part II. Obstet Gynecol Surv. 1998 Mar. 53(3):181-90. [Medline].
Varner M. Postpartum hemorrhage. Crit Care Clin. 1991 Oct. 7(4):883-97. [Medline].
Wittich AC, Salminen ER, Hardin EL, Desantis RA. Uterine packing in the combined management of obstetrical hemorrhage. Mil Med. 1996 Mar. 161(3):180-2. [Medline].
World Health Organization. Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. World Health Organization. 2007. Available at http://www.who.int/whosis/mme_2005.pdf.
Zahn CM, Yeomans ER. Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol. 1990 Sep. 33(3):422-31. [Medline].
Valent AM, Newman T, Chen A, Thompson A, DeFranco E. Gestational age-specific neonatal morbidity among pregnancies complicated by advanced maternal age: a population-based retrospective cohort study. J Matern Fetal Neonatal Med. 2015 Jun 9. 1-6. [Medline].