Postpartum Hemorrhage

By Teddyy Editorial Team | Last Updated: April 22, 2026

Excessive bleeding after childbirth, known as postpartum hemorrhage (PPH), is the leading cause of maternal death worldwide — accounting for nearly 27% of all maternal mortality according to the World Health Organization. In India, it remains one of the top three causes of death during or after pregnancy.

Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal delivery, or 1,000 ml or more after a caesarean section. It is a serious obstetric emergency that requires immediate medical attention, but with timely diagnosis and treatment, most women make a full recovery.

Understanding the causes, warning signs, and what to expect can help you stay alert and act quickly — because in cases of postpartum hemorrhage, every minute counts.

Types of Postpartum Hemorrhage

There are two types of postpartum hemorrhage, classified by when they occur:

1. Primary Postpartum Hemorrhage — Excessive bleeding that occurs within the first 24 hours after childbirth. This is the more common and more severe form.
2. Secondary Postpartum Hemorrhage — Bleeding that occurs between 24 hours and 12 weeks after delivery. This can develop gradually and is often missed or mistaken for normal lochia.

Causes of Postpartum Hemorrhage

The medical community uses the mnemonic “The Four Ts” — Tone, Trauma, Tissue, and Thrombin — to categorise the most common causes of postpartum hemorrhage.

Tone — Uterine Atony (Most Common Cause)

Uterine atony is the single most common cause of postpartum hemorrhage, responsible for approximately 70–80% of all cases. After delivery, the uterus normally contracts in response to the hormone oxytocin, which clamps the placental blood vessels shut and stops bleeding. When the uterine muscles fail to contract adequately, these vessels remain open and excessive bleeding occurs.

Risk factors for uterine atony include prolonged labour, multiple pregnancy (twins, triplets), polyhydramnios (excess amniotic fluid), large baby (macrosomia), a distended uterus, and use of certain medications such as magnesium sulphate.

Trauma — Genital Tract Injuries

Uterine trauma accounts for roughly 20% of postpartum hemorrhage cases. During labour and delivery, the physical stress of the baby passing through the birth canal can cause lacerations or tears to the uterus, cervix, vagina, and perineum. These injuries can lead to significant blood loss and, in some cases, internal haematoma (pooling of blood in a hidden area) that may not be immediately visible.

Tissue — Retained Placental Tissue

Retained placental tissue accounts for approximately 10% of postpartum hemorrhage cases. This occurs when part or all of the placenta remains attached to the uterine wall after delivery rather than being expelled naturally. Until the retained tissue is removed — either manually by a healthcare provider or surgically — the uterus cannot contract fully, and bleeding continues. A related condition called placenta accreta occurs when the placenta embeds too deeply into the uterine wall and cannot be delivered without surgical intervention.

Thrombin — Blood Clotting Disorders

Coagulation (clotting) disorders are the least common cause of postpartum hemorrhage, occurring in fewer than 1% of deliveries. A deficiency of thrombin or other clotting factors means that even minor bleeding cannot be controlled. Conditions such as von Willebrand disease, disseminated intravascular coagulation (DIC), or pre-existing blood disorders can make blood loss rapidly uncontrollable.

Risk Factors for Postpartum Hemorrhage

While postpartum hemorrhage can affect any woman, certain factors increase the risk:

• Previous history of postpartum hemorrhage
• Caesarean delivery or uterine surgery
• Prolonged or assisted labour (forceps or vacuum delivery)
• Carrying multiples (twins, triplets)
• Grand multiparity (having five or more previous deliveries)
• Placenta praevia or placenta accreta
• Pre-eclampsia or pregnancy-induced hypertension
• Anaemia during pregnancy
• Obesity (BMI above 35)

Knowing your personal risk factors before delivery allows your healthcare team to prepare preventive measures in advance.

Symptoms of Postpartum Hemorrhage — Warning Signs to Know

Some bleeding after childbirth is completely normal. However, you may be experiencing postpartum hemorrhage if you notice:

1. Soaking through a maternity pad every one to two hours or faster
2. Passing blood clots larger than a golf ball
3. Persistent and worsening pain or cramping in the abdomen and pelvic region
4. Symptoms of low blood pressure: dizziness, blurred vision, lightheadedness, or fainting
5. Nausea or feeling the urge to vomit
6. Rapid or weak heartbeat (palpitations)
7. Pale, clammy, or cold skin
8. A feeling of unusual weakness or extreme fatigue

Secondary PPH can develop days or weeks after delivery. If you have been discharged from hospital and you begin to notice heavy bleeding, foul-smelling discharge, fever, or worsening pelvic pain — seek emergency medical care immediately. Do not wait to see if it improves.

How Is Postpartum Hemorrhage Diagnosed

Your delivery team will monitor blood loss closely during and after childbirth. Diagnosis typically involves:

• Visual estimation or measurement of blood loss using calibrated drapes or collection devices
• Physical examination to assess uterine firmness, check for lacerations, and confirm placental delivery
• Blood tests including full blood count (haemoglobin levels), coagulation studies, and cross-matching in preparation for possible transfusion
• Ultrasound to detect retained placental tissue in secondary PPH cases

Treatment of Postpartum Hemorrhage

Treatment depends on the underlying cause but typically follows a rapid, stepwise approach:

Uterotonic Medications

The first line of treatment for uterine atony is administering oxytocin or other uterotonic drugs (misoprostol, ergometrine, carbetocin) to stimulate uterine contractions and stop bleeding. These medications are often given prophylactically immediately after delivery in high-risk patients.

Uterine Massage and Compression

A healthcare provider will perform bimanual uterine compression or external uterine massage to encourage the uterus to contract. Aortic compression may also be used to temporarily reduce blood flow.

Surgical Interventions

If medications and massage are not effective, surgical options include:

• Manual removal of retained placental tissue
• Surgical repair of lacerations or tears
• Uterine balloon tamponade (inserting a balloon to apply internal pressure)
• Uterine artery ligation or brace sutures (B-Lynch suture)
• Interventional radiology (uterine artery embolisation)
• In severe cases, a hysterectomy may be necessary as a life-saving measure

Blood Transfusion and Fluid Resuscitation

Significant blood loss may require a blood transfusion, administration of fresh frozen plasma (FFP), platelets, or clotting factors to stabilise the patient and restore blood volume.

Prevention of Postpartum Hemorrhage

The most evidence-based preventive measure is Active Management of the Third Stage of Labour (AMTSL), which involves:

• Administration of oxytocin immediately after the baby is delivered
• Controlled cord traction to deliver the placenta
• Uterine massage after delivery of the placenta

AMTSL has been shown to reduce the incidence of postpartum hemorrhage by up to 60%. Discuss this protocol with your obstetrician or midwife before your delivery date.

Recovery After Postpartum Hemorrhage

Recovery depends on the severity of blood loss and the treatment received. Most women recover well, but the experience can be physically and emotionally draining. During recovery:

• Rest as much as possible — your body needs time to replenish blood supply
• Eat an iron-rich diet (leafy greens, lentils, lean meat) and take prescribed iron supplements to address anaemia
• Stay adequately hydrated
• Attend all follow-up appointments — your haemoglobin levels will need to be monitored
• If you feel persistently exhausted, breathless, or low in mood, speak to your doctor — iron-deficiency anaemia and postpartum depression can both occur after significant blood loss

It is completely normal to feel anxious or traumatised after experiencing a PPH emergency. Speak to a counsellor, midwife, or trusted support person — emotional recovery is just as important as physical recovery.

When to Seek Emergency Help

Contact your doctor or go to the nearest emergency room immediately if you experience any of the following after delivery — whether you are still in hospital or have been discharged:

• Heavy bleeding that soaks through a pad in under an hour
• Large blood clots
• High fever (above 38°C / 100.4°F)
• Foul-smelling vaginal discharge
• Severe abdominal pain
• Signs of shock: dizziness, fainting, rapid heartbeat, difficulty breathing

Postpartum hemorrhage is treatable when caught early. Never hesitate to call for help.

Frequently Asked Questions About Postpartum Hemorrhage