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Related & look-alikes

Labor & postpartum Medical emergency

Postpartum hemorrhage

Also known as PPH, Postpartum bleeding. At or after birth, up to 12 weeks postpartum.

Some bleeding after birth is normal; a hemorrhage is more, losing enough blood to threaten your health, whether right after delivery or in the weeks that follow. Most of it happens in the hospital, where your team is ready, but it can also strike after you go home. So knowing the warning signs, soaking a pad an hour, golf-ball clots, feeling faint, is one of the most useful things a new parent can carry home.

Know the warning signs When to call a provider
How common
About 1% to 5% of births
The most common cause is a uterus that does not contract firmly.
When
Birth to 12 weeks after
Most in the first 24 hours; a late form can occur for weeks.
Urgency
Emergency
Soaking a pad an hour or feeling faint means 911 or the ER.
Outlook
Good with prompt care
Treatable, but speed matters; do not wait it out.

This can be a medical emergency. Soaking through more than one pad an hour If this happens, go to the ER or call 911 right away.

Understanding it

What is postpartum hemorrhage?

Postpartum hemorrhage means losing a dangerous amount of blood after giving birth. The current definition is a cumulative loss of 1,000 mL or more, or any loss with signs that your body is running low on blood, within 24 hours of birth, whether you delivered vaginally or by cesarean. It affects roughly 1% to 5% of births.

There are two timeframes. Primary hemorrhage happens within the first 24 hours, usually in the hospital. Secondary, or late, hemorrhage can happen from 24 hours up to 12 weeks after birth, often once you are home, which is why the at-home warning signs matter. Late bleeding is frequently a small piece of placenta left behind.

Doctors summarize the causes as the four T's. Tone is the uterus not contracting firmly after birth, called uterine atony, by far the most common cause, behind roughly 70% to 80% of cases. Trauma is tears of the birth canal. Tissue is placenta left in the uterus. Thrombin is a clotting problem.

It is a leading cause of maternal death worldwide, yet very treatable when caught early. Your part is to recognize the warning signs and get help quickly rather than assume heavy bleeding is normal.

Symptoms

What are the symptoms?

In the hospital, it is heavy bleeding right after birth that your team manages. At home, the warning signs of late hemorrhage are what you need to recognize and act on immediately.

Early signs

  • Heavy or persistent vaginal bleeding
  • Passing large blood clots
  • Bleeding that soaks pads quickly
  • Bleeding that had slowed and then becomes heavy again

Emergency signs — call 911

  • Soaking through more than one pad an hour
  • Passing clots bigger than a golf ball
  • Bright red bleeding that does not slow down, or that returns heavier after easing
  • Feeling faint, dizzy, or lightheaded
  • A racing or pounding heart
  • Blurry vision, or pale, cold, clammy skin

Why it matters

Risks to you and baby

Dangerous blood loss and shock

A large, fast bleed can drop your blood pressure and lead to shock, the central danger, and the reason postpartum hemorrhage is an emergency that should not wait.

Anemia and exhaustion

Even bleeding that is not life-threatening can leave you anemic, which causes fatigue, dizziness, and a slower recovery. It may need iron or, if significant, a transfusion.

Need for transfusion or procedures

Significant hemorrhage may require a blood transfusion, and persistent bleeding can need a balloon in the uterus, a procedure to block the uterine arteries, or surgery. Rarely, a hysterectomy is needed to save your life.

Your baby is already born

It affects you, not your baby directly, but recovering your strength safely is part of caring for your newborn, which is why prompt treatment matters.

How it's found

How is it diagnosed?

Postpartum hemorrhage is recognized by measuring how much blood you are losing and watching for signs of low blood volume, then quickly finding which of the four T's is responsible.

Measuring blood loss

Blood loss is measured (not just estimated) after birth. Reaching 1,000 mL, or any loss with signs of low blood volume, defines a hemorrhage.

Checking the uterus

A soft, boggy uterus that does not firm up points to atony, the most common cause. A firm uterus with ongoing bleeding suggests a tear or retained tissue instead.

Inspecting for tears and retained tissue

The birth canal is checked for tears, and the placenta is examined to be sure none was left behind, a common cause of late bleeding.

Blood tests

A blood count tracks how much you have lost, and clotting studies check for a bleeding disorder.

In the first 24 hours after birth for primary hemorrhage, or up to 12 weeks later for the secondary form, whenever bleeding is heavy or you show signs of significant blood loss.

Treatment

How is it managed?

Treatment stops the bleeding by addressing its cause and replaces what was lost. Most hemorrhage responds to a stepped approach that starts simple and escalates as needed.

Treatment paths

For the most common cause, atony, treatment begins with firm uterine massage and medicines that make the uterus contract, starting with oxytocin; tranexamic acid (TXA) helps when given early. Tears are stitched, retained placental tissue is removed, and clotting problems are corrected. If bleeding continues, a balloon inside the uterus, a procedure to block the uterine arteries, or surgery may follow, with transfusion to replace significant loss.

Medication

Oxytocin is first-line. Other uterotonics include methylergonovine (avoided with high blood pressure) and carboprost (avoided with asthma), plus misoprostol. Tranexamic acid reduces bleeding when given early.

Monitoring

Your bleeding, vital signs, and blood counts are watched closely, and treatment is stepped up quickly if bleeding does not settle.

Can it recur?

Having had one raises the risk of another, roughly 15% in a second pregnancy and higher after two. That is useful, because it lets your team plan ahead, IV access, medicines ready, and active management of the third stage of labor, all of which reduce and control it.

What you can do

Can it be prevented?

  • Active management of the third stage of labor

    Giving a uterotonic (usually oxytocin) right after birth to help the uterus contract is the main, evidence-based prevention, and now routine.

  • Identify risk ahead of time

    Knowing your risk factors, a prior hemorrhage, placenta previa or accreta, a large or multiple pregnancy, lets your team prepare, with a plan and blood available.

  • Treat anemia and know the warning signs

    Correcting anemia during pregnancy gives you more reserve, and knowing the at-home warning signs means you can get help fast if late bleeding occurs.

Who is more at risk

Risk factors

A prior postpartum hemorrhage
The strongest single predictor of another.
Recurrence of about 15% in a second pregnancy
An overstretched uterus
A large baby, twins or more, or too much amniotic fluid can leave the uterus too stretched to contract well.
Long, induced, or augmented labor
Prolonged labor and labor that is induced or sped up can tire the uterus, raising the risk of atony.
Placental problems
Placenta previa, placenta accreta, and a retained placenta are important causes of heavy bleeding.
Other factors
Infection in labor (chorioamnionitis), preeclampsia, having had many prior births, obesity, and bleeding or clotting disorders all increase risk.

Do not wait

When to call your provider or 911

  • Call 911 or go to the ER if you soak more than one pad an hour, pass clots bigger than a golf ball, or feel faint, dizzy, or have a racing heart.
  • Seek emergency care for bright red bleeding that does not slow after the first days, or that had slowed and then becomes heavy again.
  • Go in for pale, cold, or clammy skin, or blurry vision, which can be signs of significant blood loss.
  • Do not assume heavy bleeding weeks after birth is normal; late hemorrhage can happen up to 12 weeks out, often from retained placental tissue.
  • Trust your instinct: if something feels wrong in your recovery, call. It is always better to be checked.

Talking to your team

Questions to ask your provider

  • What is causing my bleeding, and which of the four T's is it?
  • How much blood have I lost, and do I need a transfusion?
  • What medications or procedures are you using to stop it?
  • Am I at higher risk for this, and what is the plan for a future birth?
  • What bleeding is normal in my recovery, and what should send me back in?
  • Do I need iron or other treatment for anemia before I go home?

Keep reading

More on postpartum hemorrhage

All pregnancy guides articles

Good to Know

Postpartum hemorrhage FAQs

Common questions about postpartum hemorrhage, answered.

How much bleeding after birth is normal, and how much is too much?

Some bleeding, called lochia, is normal for weeks and gradually lightens and changes color. The warning line is heavy bleeding: soaking more than one pad an hour, passing clots bigger than a golf ball, or bright red bleeding that does not slow. Those, or feeling faint, mean call 911 or go to the ER.

What are the warning signs once I am home?

Soaking more than a pad an hour, passing large clots, bleeding that returns heavier after easing, feeling faint or dizzy, a racing heart, and pale or clammy skin. Any of these means an immediate call to 911 or a trip to the ER.

Can postpartum hemorrhage happen after I leave the hospital?

Yes. Secondary, or late, hemorrhage can occur from 24 hours up to 12 weeks after birth, often once you are home. It is frequently caused by a piece of placenta left behind, and needs prompt evaluation.

What causes it?

Doctors group the causes as the four T's: Tone (the uterus not contracting, the most common), Trauma (tears), Tissue (retained placenta), and Thrombin (a clotting problem). Knowing the cause guides the treatment.

Will I need a blood transfusion or a hysterectomy?

A transfusion is sometimes needed for significant loss and is a routine, life-saving step. A hysterectomy is a rare last resort, only when bleeding cannot be controlled any other way. Most hemorrhage stops with medicines and simpler measures.

Will it happen again in my next birth?

Having had one raises the risk, roughly 15% in a second pregnancy. That is useful, because your team can plan ahead with IV access, medicines ready, and active management right after birth.

Why does stopping the bleeding depend on the uterus contracting?

During pregnancy a large amount of blood flows to the placenta. After birth the uterus contracts to squeeze those vessels shut, like a natural clamp. If it stays soft, they keep bleeding, which is why massage and uterus-contracting medicines are the first response.

Is postpartum hemorrhage dangerous?

It can be, and it is a leading cause of maternal death worldwide. But that reflects places where care is delayed. With prompt recognition and treatment, the great majority recover fully, which is exactly why knowing the warning signs matters.

Medically Reviewed · Updated

Reviewed by Dr. Grace Lin, MD, FACOG · OB-GYN

Obstetrician-gynecologist focused on reproductive and sexual health for women: pregnancy, BV, yeast, trichomoniasis and HPV/cervical screening. Our editorial guidelines →

6 Sources

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