By: Judy Greenwood and Victoria Guituan
What is postpartum hemorrhage (PPH)?
Postpartum hemorrhage is defined as excessive blood loss quantified as 1,000 mL or greater with signs of hypovolemia within 24 hours of birth (Postpartum Hemorrhage, 2017). Signs of hypovolemia include cool, clammy skin, fatigue, pallor (pale skin), decreased level of consciousness, and generalized weakness (Hypovolemic Shock: MedlinePlus Medical Encyclopedia, 2024). Primary postpartum hemorrhage occurs within 24 hours of birth, while secondary postpartum hemorrhage can occur up to 12 weeks after birth (Postpartum Hemorrhage, 2017). Postpartum hemorrhage is one of the most common complications following childbirth and can lead to further complications if not treated rapidly.
How does it occur?
Postpartum hemorrhage is caused by the 4 T’s: tone (uterine tone), trauma (uterine trauma), tissue (retained placental tissue or clots), and thrombin (blood clotting deficiencies) (Wormer et al., 2024; Postpartum Hemorrhage (PPH): Causes, Risks & Treatment, 2023). The most common cause of PPH is generally due to the lack of uterine contractions after childbirth. This is essential because uterine contractions are responsible for expelling blood clots and returning the uterus to its normal size. After birth, the uterus should begin to feel firm, instead of boggy or soft.
Other causes may include blood loss during a cesarean section, delayed placental delivery after birth of the child, lacerations or ruptures, and previously diagnosed clotting disorders.
Signs and Symptoms of PPH
Signs and symptoms of PPH mirror hypovolemic shock. This may include feeling faint, cool or clammy skin, sweating, a decreased level of consciousness, a drastic drop in blood pressure, increased heart rate, and excessive and uncontrolled blood loss quantified as ≥ 1,000 mL of blood within 24 hours or up to 12 weeks after childbirth.
Treatment
Initial treatment of PPH generally includes a fundal massage and administration of Pitocin (oxytocin). Massaging the fundus of the uterus helps to expel clots and to help promote uterine contractions. Similarly, oxytocin is a naturally occurring hormone that plays a role in promoting uterine contractions. This can be administered in its synthetic form as Pitocin to help reduce hemorrhaging. The most important factor to consider when treating PPH is to determine the cause and to treat the source of bleeding directly.
To account for the large amount of blood loss, providers may initiate blood transfusions to help restore blood (Bienstock et al., 2021).
Severe Complications Associated with PPH/Timing in Treatment
If left untreated, PPH can result in serious complications. Other complications include infection, hypovolemic shock from immense blood loss, acute renal (kidney) failure, hepatic (liver) failure, excessive clotting, also known as disseminated intravascular coagulation (DIC), and death (Bienstock et al., 2021).
Timing in treatment and early recognition of risk factors are essential in reducing adverse outcomes, such as maternal mortality. Some risk factors that may increase the likelihood of PPH include anemia, cesarean section, multiparity (having multiple pregnancies), macrosomia (neonate that weighs more than 9 lbs at birth), and shoulder dystocia (shoulder of the neonate becoming stuck during childbirth) (UpToDate, 2025). Without adequate timing in treatment, excessive blood loss can cause other organ systems to shut down due to the lack of oxygen, which can ultimately result in death. Failure to identify alarming risk factors and to intervene is considered to be negligent, where one may face adverse outcomes if not treated accordingly.
Reduce hemorrhaging. The most important factor to consider when treating PPH is to determine the cause and to treat the source of bleeding directly. To account for the large amount of blood loss, providers may initiate blood transfusions to help restore blood (Bienstock et al., 2021).
Severe Complications Associated with PPH/Timing in Treatment If left untreated, PPH can result in serious complications. Other complications include infection, hypovolemic shock from immense blood loss, acute renal (kidney) failure, hepatic (liver) failure, excessive clotting, also known as disseminated intravascular coagulation (DIC), and death (Bienstock et al., 2021).
Timing in treatment and early recognition of risk factors are essential in reducing adverse outcomes, such as maternal mortality. Some risk factors that may increase the likelihood of PPH include anemia, cesarean section, multiparity (having multiple pregnancies), macrosomia (neonate that weighs more than 9 lbs at birth), and shoulder dystocia (shoulder of the neonate becoming stuck during childbirth) (UpToDate, 2025). Without adequate timing in treatment, excessive blood loss can cause other organ systems to shut down due to the lack of oxygen, which can ultimately result in death. Failure to identify alarming risk factors and to intervene is considered to be negligent, where one may face adverse outcomes if not treated accordingly.
