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:
When the uterus has been stretched too much—for example, by too much amniotic fluid in the uterus Too much amniotic fluid Amniotic fluid is the fluid that surrounds the fetus in the uterus. The fluid and fetus are contained in membranes called the amniotic sac. Problems with amniotic fluid include Too much amniotic... read more , by several fetuses (multiple births Multiple Births The term multiple births refers to the presence of more than one fetus in the uterus. The number of twin, triplet, and other multiple births has been increasing during the last two decades.... read more ), or by a very large fetus Large-for-Gestational-Age (LGA) Newborns A newborn who weighs more than 90% of newborns of the same gestational age at birth (above the 90th percentile) is considered large for gestational age. Newborns may be large because the parents... read more
When labor was prolonged, abnormal, or rapid
When a woman has delivered five or more babies
When a muscle-relaxing anesthetic was used during labor and delivery
When the membranes around the fetus are infected (called intra-amniotic infection Intraamniotic Infection Intraamniotic infection is infection of the tissues around the fetus, such as the fluid that surrounds the fetus (amniotic fluid), the placenta, the membranes around the fetus, or a combination... read more )
Excessive bleeding can also result when the following occurs:
When the vagina or cervix is torn during delivery
When the cut made during an episiotomy Delivery of the baby
extends too farWhen a woman has a bleeding disorder that interferes with clotting Overview of Blood Clotting Disorders Blood clots help stop bleeding. Blood clotting (coagulation) disorders are dysfunctions in the body's ability to control the formation of blood clots. These dysfunctions may result in Too little... read more
When intra-amniotic infection leads to infection of the uterus Infections of the Uterus After Delivery Infections that develop after delivery of a baby ( postpartum infections) usually begin in the uterus. Bacteria can infect the uterus and surrounding areas soon after delivery. Such infections... read more (called endometritis)
When a piece of the placenta remains inside the uterus after delivery
Rarely, when the uterus ruptures Uterine Rupture Uterine rupture is a spontaneous tearing open of the uterus that may result in the fetus floating in the abdomen. Rupture of the uterus is very rare. It is an emergency requiring immediate treatment... read more or is turned inside out (inverted Inverted Uterus Very rarely, the uterus is turned inside out (inverted), so that it protrudes through the cervix and into or through the vagina. The uterus may be inverted if the placenta is firmly attached... read more )
Excessive bleeding after one delivery may increase the risk of excessive bleeding after subsequent deliveries.
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. Oxytocin helps the uterus contract and 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
Removal of any remaining fragments of the placenta
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. Any fragments that remain in the uterus are removed by hand. Rarely, dilation and curettage Dilation and Curettage Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more 
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.
A device that applies gentle suction to the uterus and thus helps the uterus contract may be placed in the uterus.
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.
