bleeding (postpartum haemorrhage)
Last edited 04/2021 and last reviewed 09/2022
This is bleeding from the genital tract after the delivery of a baby.
It can be broadly divided into primary and secondary types, the distinction being the timing of the onset of the bleed relative to the delivery (1,2).
A primary postpartum haemorrhage is a loss (usually defined as more than 500ml) in the first 24 hours after delivery.
It is important to note that in pregnancy the clinical parameters may be unreliable; for example, apparent normotension can be due to pre-eclampsia combined with blood loss.
Postpartum bleeding - Postnatal Care (3)
Discuss with women what vaginal bleeding to expect after the birth (lochia), and advise women to seek medical advice if:
- the vaginal bleeding is sudden or very heavy
- the bleeding increases
- they pass clots, placental tissue or membranes
- they have symptoms of possible infection, such as abdominal, pelvic or perineal pain, fever, shivering, or vaginal bleeding or discharge has an unpleasant smell
- they have concerns about vaginal bleeding after the birth
If a women seeks medical advice about vaginal bleeding after the birth, assess the severity, and be aware of the risk factors for postpartum haemorrhage
Antenatal risk factors:
previous retained placenta or postpartum haemorrhage
maternal haemoglobin level below 85 g/litre at onset of labour
BMI greater than 35 kg/m2
grand multiparity (parity4 or more)
overdistention of the uterus (for example, multiple pregnancy, polyhydramnios or macrosomia)
existing uterine abnormalities
maternal age of 35 years or older.
Risk factors in labour:
prolonged first, second or third stage of labour
operative birth or caesarean section
Also be aware of the following factors, which may worsen the consequences of secondary postpartum haemorrhage:
- weight of less than 50 kg at the first appointment with the midwife during pregnancy (booking appointment).
Prevention of postpartum haemorrhage (2):
- traditionally, oxytocin and ergot preparations have been used as uterotonic
agents for postpartum haemorrhage prophylaxis mostly as part of active management
of the third stage of labour
- a major disadvantage, mainly related to ergot preparations, is the relatively high incidence of side-effects such as nausea, vomiting and increase in blood pressure
- misoprostol may prevent severe postpartum haemorrhage but the evidence is
- misoprostol or intramuscular postaglandins are not more effective than conventional injectable uterotonics - both lead to more adverse effects
- the review concludes that neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.
primary postpartum haemorrhage
secondary postpartum haemorrhage