When a Drizzle Becomes a Downpour: Post-Partum Hemorrhage

Bleeding after baby is nothing to say “boo” about. It happens to everyone, and it’s normal. First comes baby, then comes placenta, then comes bleeding. It’s a pretty standard course of events. For most women, the bleeding is moderate and slows down pretty quickly. Although pads become our good pals in the postpartum period, we are usually ready to break up with them after about four weeks. However, for some women, bleeding after baby (a.k.a. post-partum) can be heavy, heavier, and heaviest. When it starts and is difficult to stop, we call it a post-partum hemorrhage (a.k.a. PPH).

PPH can be the real deal. In fact, post-partum hemorrhage is the number-one cause of maternal mortality worldwide. It’s estimated that about every four minutes, a woman dies from PPH somewhere in the world. It’s a very serious problem. When the excessive bleeding occurs within 24 hours of Baby’s arrival, the PPH is classified as a primary PPH.

Almost all of the primary PPHs occur because the uterus is unable to contract or clamp down. Other likely causes include a retained placenta and blood clotting problems. Secondary PPH occurs between 24 hours and 6 to 12 weeks postpartum. When you see the red faucet turning on, off, and then on again, it is usually from retained placental tissue, abnormal placental attachment, infection, or clotting disorders.

As OBs we develop a pretty strong stomach and pretty thick skin. Very few things make us nervous or make us break a sweat. However, one exception to this rule is a bad PPH, the kind that seems to have no end in sight. If you should find yourself floating down this river, this is what your OB will do:

1. She/he will start looking and start massaging. Uterine massage is the first move in this situation—most women are bleeding because the uterus has not yet contracted. Massage will move the uterus closer to contraction.
2. When you still feel the pain or are still bleeding despite massage, medications come next. IV infusions, IM shots, and possibly even a trip to the operating room can be in your near future.
3. Surgical interventions are reserved for really free-flowing situations, and we only go there when we have no place else to go. However, if we need to bring out the big guns to put an end to the bleeding, we can do it.
4. If we need to call in our peers from other parts of the hospital—radiologists, interventional radiologists, surgeons, the blood products lab, etc.—we will. As the captain of the team, we need a good offensive line to defend the blitz. We may even need to transfuse blood products to keep you safe and keep things steady.

Secondary PPH is treated in more of a sly manner. It is not as dramatic, at least initially, as primary PPH. It can happen while you are still chilling in the hospital or hanging at home. As you can imagine, the latter can be very scary. While it is very rare (about 1%) of all pregnancies, it is usually due to retained placental tissue (darn thing just won’t go away!). It can also be an expression of an underlying blood clotting disorder that you never knew existed. In most of these cases, the first person on speed dial should be your OB/GYN. They will want to see you ASAP. They will often send you for one ultrasound and possibly more. While the operating room may be in your near future, we hope to avoid it. Too many trips to the OR, particularly in the post-partum period, can lead to scar tissue.

Although we can’t always predict who will bleed heavily in the post-partum period, it is not simply a game of eenie meenie miney mo; there are some red flags. Risk factors include long labors, fast labors, assisted labors, and labors that needed Pitocin (did we leave any labors out?). They also include a history of PPH in prior pregnancies, elevated blood pressure, a big uterus that held more than one baby, and infection. The best way to treat a PPH is to be prepared. Therefore, if you fall into one or more of these categories, we may full court press you, even if it’s just an easy jump shot. We would rather overreact than under prepare.

When the drizzle turns into a pour and you have forgotten your umbrella at home, you will kick yourself for not listening to the weather report. Drizzle, we can deal with. Nothing gets ruined, and it passes quickly. A downpour is a whole different situation. The same can be said for bleeding post-partum. Minimal or moderate bleeding is normal, doable, and “deal-able.” A little massage and medication and you are on your way. The more serious stuff can be dangerous. Downpours can turn into thunderstorms and hurricanes, if you don’t act quickly. Make sure you have shared your whole medical history with your OB/GYN, as this will serve as their trusty weather app. We don’t want to leave anyone out in the storm!