Postpartum haemorrhage

The purpose of this leaflet is to provide patients with information about the nature, development, risk factors, symptoms and treatment of postpartum haemorrhage.

Bloody discharge from the vagina is to be expected after childbirth. It is due to the healing of the inner lining of the uterus, known in obstetrics as uterine involution. The bleeding usually originates from the area of the uterus where the placenta was attached, but it can also be due to cervical, vaginal and perineal tears caused by childbirth. The bleeding is more significant immediately after childbirth and gradually decreases over the next hours and days. Postpartum discharge typically lasts for an average of 6 to 12 weeks.

What is a postpartum haemorrhage?

Postpartum haemorrhage is defined as blood loss of more than 500 ml after vaginal delivery and more than 1000 ml after caesarean section.

The frequency of postpartum haemorrhage is 6–11% of births. Dangerous haemorrhage occurs in 13% of births.

There are four main causes of postpartum haemorrhage:

  • uterine atony, i.e. the uterus does not contract enough after delivery;
  • retention of the placenta or parts of the placenta in the uterus;
  • birth canal injuries;
  • blood clotting disorders.

There are two types of postpartum haemorrhage:

  • early or primary postpartum haemorrhage occurs within the first 24 hours after childbirth;
  • late or secondary postpartum haemorrhage occurs between 24 hours and 12 weeks after childbirth.

Risk factors for early postpartum haemorrhage

During pregnancy

  • Previous postpartum haemorrhage (risk of recurrence 8-10%)
  • Previous caesarean section
  • Overdistended uterus – multiple pregnancy, excessive amniotic fluid, large foetus
  • Preeclampsia or elevated blood pressure during pregnancy
  • Placenta praevia or low placental attachment
  • Placental abruption
  • Body mass index (BMI) > 35
  • Body weight < 60 kg
  • Anaemia during pregnancy
  • Uterine anomalies and fibroids
  • Blood clotting disorders
  • Use of blood thinners

During childbirth

  • Caesarean section, especially during the expulsion phase
  • Induced labour
  • Use of oxytocin to stimulate labour activity
  • Prolonged placental period (retention of the placenta or placental fragments)
  • Perineal tears or episiotomy
  • Vacuum or forceps-assisted delivery
  • Prolonged labour (> 12 hours)
  • Large foetus (> 4 kg)
  • First childbirth after the age of 40
  • Elevated body temperature (fever), uterine infection
  • Use of general anaesthesia

An important factor contributing to postpartum haemorrhage is anaemia during pregnancy. Iron replacement therapy during pregnancy reduces the need for blood transfusion after delivery.

How can postpartum haemorrhage occur?

During and after delivery, the midwife assesses blood loss by massaging the uterus to ensure uterine contraction. Dizziness, lightheadedness, rapid pulse, paleness, nausea and blurred consciousness are signs of increased blood loss. Postpartum haemorrhage can progress very quickly. Without timely and professional help, the situation can be life-threatening.

Prevention and treatment

Oxytocin is used to prevent postpartum haemorrhage and is administered either by intramuscular or intravenous injection. Oxytocin triggers uterine contraction and speeds up placental expulsion.

After delivery, the tears are assessed and sutured. In case of haemorrhage, various treatment methods are used medications are administered via injection or intravenous infusion and different procedures or surgeries are performed if necessary (examination of the uterine cavity, insertion of a balloon catheter and, in life-threatening cases, removal of the uterus).

After haemorrhage

The mother continues to be monitored and treated in the intensive care unit. For anaemia, or poor blood count, iron replacement therapy for 68 weeks and a blood test at your general practitioner is recommended. If necessary, the doctor will prescribe a blood thinner for 10 days to 6 weeks, as the risk of thrombosis increases after haemorrhage.

Late postpartum haemorrhage

Late or secondary postpartum haemorrhage may be due to inflammation of the uterus or, less commonly, retention of placental fragments in the uterus. It usually occurs within 24 hours to 12 weeks after childbirth. If bleeding increases significantly after childbirth, discharge becomes foul-smelling and symptoms like discomfort, weakness or fever arise, it is important to contact a doctor or midwife or visit the emergency department at the Women’s Clinic.

In this case, antibacterial treatment may be necessary and, in rarer cases, surgery to remove parts of the placenta left in the uterus.


Approved by the decision of the Care Quality Commission of East Tallinn Central Hospital on 20.09.2023 (protocol no. 15-23)