Postpartum haemorrhage

What is normal vaginal bleeding after birth?

It is normal to have some bleeding from your vagina after birthing your baby — this bleeding is known as 'lochia'. It usually comes from the area of your uterus where the placenta was attached and this wound needs to heal like any other abrasion or cut. You may also have bleeding from any tears or cuts caused during birth.

Bleeding will typically be heaviest in the first few days after birth and slowly becomes less over the next days and weeks.

It is often bright red, like a heavy period, in the first few days after birth. The colour of your blood loss may change over the course of the next few days and weeks from bright red, to reddish-brown, brown and eventually pink-ish as your bleeding slows down and eventually stops. The colour of your blood loss can vary from person to person.

Bleeding after birth typically lasts up to 4 to 6 weeks, although this varies.

You may experience heavier bleeding in the morning when you get out of bed, after exercise and after breastfeeding.

What is postpartum haemorrhage?

Postpartum haemorrhage (PPH) is when you bleed more than normal after giving birth. It's defined as losing more than 500ml of blood from your vagina after birth.

If you have heavy bleeding within the first 24 hours after the birth, it's called a primary postpartum haemorrhage. If the bleeding happens more than 24 hours but less than 6 weeks later, it's called a secondary postpartum haemorrhage.

Postpartum haemorrhage is serious and can be life-threatening. You need urgent medical attention to stop the bleeding.

Postpartum haemorrhage happens in 5 to 15 out of every 100 births in Australia. Most of the time it happens within the first 24 hours.

How do I know if I’m bleeding too much?

While bleeding after birth is normal, you may be having a postpartum haemorrhage if you gave birth more than 24 hours ago and:

• you are soaking through a pad every hour or two
• you are passing large clots
• the blood suddenly changes to bright red in colour
• the amount of blood loss suddenly increases
• you feel tired, dizzy or are having trouble breathing
• you are concerned about your blood loss

Depending on what’s causing your bleeding, you might also experience:

• fever
• pain in your lower abdomen
• an unpleasant smell with the bleeding

When should I seek medical help?

If you are bleeding heavily (soaking through a pad every hour or two) and you have given birth within the last 6 weeks, go to your hospital's emergency department.

Call triple zero (000) and ask for an ambulance if you:

• have given birth within the last 24 hours
• feel unwell, dizzy or clammy
• feel your heart racing
• are short of breath

Contact your doctor or midwife immediately if you:

• are unsure whether your bleeding is normal
• have a fever over 38°C
• notice any unusual vaginal discharge
• have worsening abdominal pain

What causes postpartum haemorrhage?

Primary postpartum haemorrhage (occurring in the first 24 hours after birth) is most commonly caused by your uterus (womb) not contracting as it should. Normally, the uterus contracts to push out the placenta and stop bleeding from the large blood vessels that supplied blood to the placenta. If your uterus does not contract well, these blood vessels can continue to bleed.

It can also happen due to:

• an injury to your uterus, cervix, vagina or perineum
• part or all of the placenta not coming out of the uterus
• problems with blood clotting

Secondary postpartum haemorrhage (occurring between 24 hours and 6 weeks after birth) is most often caused by an infection in the uterus or by part of the placenta being left inside your uterus. It can occasionally be caused by other problems, such as fibroids.

What are the risk factors for postpartum haemorrhage?

Most people who have a postpartum haemorrhage don't have any known risk factors. It can happen unexpectedly to anyone.

However, it is more likely if you have:

• given birth 5 or more times before — the risk goes up with each birth
• a very stretched uterus — for example, if you are carrying a large baby or multiple babies or if you have a lot of amniotic fluid
• a problem with how or where the placenta is attached to your uterus, such as placenta praevia
• a bleeding disorder
• had a postpartum haemorrhage before
• uterine fibroids
• other health conditions — such as a BMI over 35, high blood pressure, anaemia or diabetes

The type of birth you have can also increase your risk of a PPH. You are at a higher risk if:

• you have a very long or very fast labour
• you are induced to start labour
• you have an assisted birth with forceps or vacuum or a caesarean
• you have an episiotomy
• part or all of the placenta doesn't come out after birth
• you have a fever during labour
• your baby's shoulders get stuck in the birth canal during birth

How is postpartum haemorrhage treated?

Primary PPH

Postpartum haemorrhage is a medical emergency. To treat it, your medical team will insert a needle into your vein (called an IV) to provide you with fluids. They may insert a catheter (tube) into your bladder to monitor your urine.

They will examine you to find the cause of the bleeding. They will monitor you closely by checking your blood pressure and pulse.

Treatment of postpartum haemorrhage depends on what is causing it and how much blood you have lost. It may include:

• massaging your uterus by pressing on your abdomen — this will help it contract and push the placenta out
• medicines to reduce the bleeding
• a blood transfusion
• surgery in an operating room under anaesthetic

If you need surgery, it may involve:

• removing the placenta or any membranes or blood clots remaining in your uterus
• repairing any injuries causing bleeding
• inserting a balloon into your uterus to put pressure on the bleeding area
• hysterectomy (removing the uterus) — in very rare cases, this may be the only way to stop the bleeding and save your life

After surgery, you will be closely monitored in hospital, often in an intensive care unit (ICU).

Secondary PPH

Postpartum haemorrhage that starts more than 24 hours after giving birth is usually treated with antibiotics. You may also need medicine to help your uterus contract, or surgery to remove any tissue that is still inside your uterus.

If you have lost a lot of blood, you may need additional treatment, such as fluids, medicines or a blood transfusion.

Can postpartum haemorrhage be prevented?

Postpartum haemorrhage is unpredictable, so it’s important that everyone giving birth has access to emergency medical care after having their baby.

It’s recommended to receive medicine during the third stage of labour to help birth the placenta, instead of waiting for it to come out on its own. This can reduce your chance of having a PPH. You should speak to your doctor or midwife about this before labour. This discussion may help you make a decision about what is right for you.

It’s very important that you have an ultrasound during pregnancy to check the position of your placenta. If you have placenta praevia, you may be able to plan ahead for birth to avoid life-threatening bleeding.

If you are at a higher risk of having postpartum haemorrhage, your doctor or midwife will discuss with you where it is safest for you to give birth. You might be advised to have an intravenous cannula (IV) inserted during labour in case you need medicines or fluids urgently.

Complications of postpartum haemorrhage

If you lose a lot of blood, you might develop anaemia. Your doctor can check this with a blood test. You may need iron therapy or a blood transfusion.

Sometimes breastfeeding is more difficult after a postpartum haemorrhage. Speak to your midwife or a lactation consultant if you are having trouble with breastfeeding.

Having a postpartum haemorrhage increases your risk of developing a blood clot. You can reduce your chance of developing a clot by staying active and drinking plenty of water. Speak to your doctor to see if there’s anything else you should do to prevent blood clots.

If your labour doesn’t go as planned, you may feel negative emotions about your birth experience. You may feel upset or anxious about what happened. It can help to talk to someone.

Will postpartum haemorrhage affect my pregnancies in the future?

You have a higher chance of having another postpartum haemorrhage in future pregnancies if you have had one before, so it’s very important to let your medical team know during your next pregnancy. There are steps they can take to reduce your chance of experiencing a PPH again.

If you’re worried about the possibility of a postpartum haemorrhage in future pregnancies, talk to your doctor or midwife. They can explain what happened and may ease your concerns.

Resources and support

Talk to your doctor or midwife if you have any concerns about postpartum haemorrhage.

If you have experienced a PPH and are finding it hard to cope, call or visit:

• Perinatal Anxiety and Depression Australia (PANDA) on 1300 726 306
• Australasian Birth Trauma Association
• Beyond Blue on 1300 22 4636