Updated: 6/5/2020

Postpartum Hemorrhage

Review Topic
  • Snapshot
    • A 17 year-old G1P1 woman undergoes a spontaneous delivery of a 4200 g (9 lb 4 oz) newborn boy with Apgar scores of 8 and 9 at 1 and 5 minutes. She began experiencing the onset of regular contractions 8 hours before delivery. She was administered IV oxytocin for the last 5 hours of labor. After the placenta was delivered, she experienced postpartum hemorrhage with an estimated blood loss of 1200 mL.
  • Introduction
    • Overview
      • postpartum hemorrhage is defined as blood loss of ≥ 500 mL after vaginal delivery or > 1000mL of blood after cesarean delivery
        • leading cause of maternal mortality
  • Epidemiology
    • Incidence
      • occurs in approximately 5-13% of pregnancies in the US and industrialized countries
    • Pathophysiology
      • usually occurs immediately after the delivery of the placenta
      • potential etiologies
        • uterine atony
          • most common (90% of postpartum hemorrhages)
          • defined as a boggy and enlarged uterus
          • normally, the uterus contacts and compresses down on spiral arteries
            • uterine atony and failure of contraction can lead to rapid and severe hemorrhage
        • retained placental tissue
          • occurs when separation of placenta from uterine wall or expulsion of placenta is incomplete
            • may occur with placenta accreta
          • complete detachment and expulsion of the placenta allows uterine retraction and ↑ occlusion of blood vessels
        • trauma (i.e., lacerations)
          • uterine rupture
            • most common in patients with previous cesarean delivery scars
          • cervical laceration is most commonly associated with forceps delivery
          • vaginal sidewall laceration is associated with operative vaginal delivery
          • lower vaginal trauma may occur due to episiotomy
        • coagulation disorder
          • underlying bleeding disorders should be considered in woman with the following risk factors
            • history of menorrhagia
            • family history of bleeding disorders
            • personal history of severe bruising without known injury
            • epistaxis of > 10min duration
          • acquired coagulation abnormalities (i.e., DIC)
            • disseminated intravascular coagulation (DIC) may be related to abruptio placentae (see illustration), HELLP syndrome, intrauterine fetal demise, and amniotic fluid embolism
        • uterine inversion
          • occurs when the uterine fundus is pulled inferiorly into the uterine cavity
  • Presentation
    • Symptoms
      • heavy vaginal bleeding
      • signs and symptoms of hypovolemic shock
        • tachycardia
        • quick, shallow breathing
        • weakness and fatigue
        • confusion
        • cool and clammy skin
  • Treatment
    • Medical
      • fluid resuscitation
      • blood transfusion
      • fresh frozen plasma and cryoprecipitate infusions if abnormal coagulation test findings
      • manage underlying causes
        • uterine atony
          • bimanual uterine massage to stimulate contractions
          • oxytocin administration
    • Surgical
      • suturing of lacerations
      • uterine artery ligation
        • uterine arteries provide 90% of uterine blood flow
      • hysterectomy
        • curative for bleeding arising from the uterus, cervix, and vagina
  • Complications
    • Hemodynamic instability and organ failure
      • incidence
        • up to 60% of women wiht postpartum hemorrhage
      • treatment
        • fluids and blood transfusion
    • Sheehan syndrome (i.e., postpartum hypopituitarism)
      • pituitary gland is prone to infarction from hypovolemic shock due to severe postpartum hemorrhage
      • incidence
        • rare
      • treatment
        • supplementation of pituitary hormones

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(M2.OB.17.4870) A 30-year-old G4P3 woman at 38 weeks gestation is admitted to the labor and delivery unit complaining of contractions every 5 minutes for the past hour. Her previous births have been via uncomplicated caesarean sections, but she wishes to attempt vaginal delivery this time. Her prenatal care is notable for gestational diabetes controlled with diet and exercise. The delivery is prolonged, but the patient's pain is controlled with epidural analgesia. She delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Fundal massage is performed, but the placenta does not pass. The obstetrician manually removes the placenta, but a red mass protrudes through the vagina attached to the placenta. The patient loses 500 mL of blood over the next minute, during which her blood pressure decreases from 120/80 mmHg to 90/65 mmHg. What is the best next step in management?

QID: 109563

Uterine artery ligation






Intravenous oxytocin



Elevate posterior fornix



Red blood cell transfusion



M 7 D

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(M2.OB.17.4869) A 22-year-old G4P2 at 35 weeks gestation presents to the hospital after she noticed that "her water broke." Her prenatal course is unremarkable, but her obstetric history includes postpartum hemorrhage after her third pregnancy, attributed to a retained placenta. The patient undergoes augmentation of labor with oxytocin and within four hours delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Three minutes later, the placenta passes the vagina, but a smooth mass attached to the placenta continues to follow. Her temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 90/min, and respirations are 20/min. What is the most likely complication in the absence of intervention?

QID: 109562

Heart failure



Hemorrhagic shock












M 8 D

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(M2.OB.14.80) A 31-year-old G6P6 woman with a history of fibroids gives birth to twins via vaginal delivery. Her pregnancy was uneventful, and she reported having good prenatal care. Both placentas are delivered immediately after the birth. The patient continues to bleed significantly over the next 20 minutes. Her temperature is 97.0°F (36.1°C), blood pressure is 124/84 mmHg, pulse is 95/min, respirations are 16/min, and oxygen saturation is 98% on room air. Continued vaginal bleeding is noted. Which of the following is the most appropriate initial step in management?

QID: 106951

Bimanual massage



Blood product transfusion






Uterine tamponade



Uterine artery embolization



M 7 E

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