#407: Managing Postpartum Hemorrhage

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In today’s episode, we’re talking about Postpartum Hemorrhage, or PPH—a potentially life-threatening complication that requires swift recognition and intervention from the nurse. It is actually one of the top five causes of maternal mortality, which makes timely recognition and prompt treatment absolutely crucial.

Whether you’re studying for an exam or gearing up for your OB clinical, this is one of those must-know topics. We’re going to break it down using the LATTE method…but first, let’s lay the foundation with some pathophysiology, risk factors, and potential complications.

Pathophysiology of postpartum hemorrhage

In normal physiology, the coagulation cascade and uterine contractions regulate blood loss after birth. When these mechanisms are disrupted, blood loss can be significant, and if left untreated, lead to severe complications. Different organizations define the amount of blood loss that qualifies as PPH a bit differently. A few key ones are: 

• The World Health Organization:
  • Blood loss > 500 ml within 24 hours after birth
• American College of Obstetricians and Gynecologists:
  • Cumulative blood loss > 1000 ml accompanied by signs and symptoms of hypovolemia within 24 hours of birth
• California Maternal Quality Care Collaborative:
  • Blood loss > 500 ml following vaginal delivery or 1000 ml following cesarean delivery; 
  • or VS indicating hypovolemia (tachycardia, hypotension, and SpO2 < 95%)

So why does PPH happen?

The main causes of PPH can be summed up with the “Four T’s” which are tone, tissue, trauma and thrombin. 

• Tone: The most common cause is uterine atony. This is when the uterus does not contract effectively after delivery which prevents mechanical hemostasis from occurring. Risk factors for atony include prior postpartum hemorrhage, prolonged labor, multiple gestation, induced labor, fibroids, polyhydramnios, and magnesium sulfate therapy for preeclampsia (among others).
  
• Tissue: Retained placental fragments or tissue prevent the uterus from contracting fully. Risk factors include placental disorders such as placenta accreta spectrum (a condition in which the placenta adheres abnormally to the uterine wall), placenta previa, placental abruption, retained placenta, and low-lying placenta.
  
• Trauma: Lacerations, surgical incisions, uterine rupture, or hematomas can cause postpartum hemorrhage. Risk factors for trauma related causes include use of instrument-assisted vaginal birth, a persistent occiput posterior position, and a midline episiotomy.
  
• Thrombin: Coagulopathy that prevents adequate blood clotting. In addition to patients with preexisting conditions such as von Willebrand disease, other risk factors for coagulopathy include placental abruption, preeclampsia, HELLP syndrome, fetal demise, sepsis, and amniotic fluid embolism.

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L: How does the patient LOOK?

Postpartum hemorrhage can present subtly or dramatically. Here’s what to look for:

• Increased lochia – bright red bleeding that saturates a peripad more than expected
• Large blood clots
• A boggy, soft uterus upon palpation
• Tachycardia and hypotension (note these may be late signs)
• Pallor, dizziness, or feeling faint
• Anxiety or restlessness, which could be early signs of hypoperfusion

A: How do you ASSESS the patient?

Key nursing assessments for a patient with suspected or active PPH:

Uterine tone and position – A normal assessment should reveal a uterus that is firm and in the proper position relative to how much time has lapsed since delivery:

• To assess uterine tone, position the patient in a supine or low semi-Fowler’s position with knees flexed. Stabilize the uterus with one hand, cup the other hand over the fundus and press firmly. The fundus should feel firm. If it does not, this indicates uterine atony and places the patient at high risk for postpartum hemorrhage.
• To assess fundal position, you’re looking at its location in relation to the umbilicus. About one hour after delivery, the fundus should be midline and at the level of the umbilicus.

Amount of bleeding – Blood that can be collected and measured in a graduated cylinder provides the most accurate way to quantify blood loss. However, many times the blood has saturated a peripad or bedding. While you may see blood loss estimated by visual inspection, studies show that quantitative measurements are more accurate. In order to determine how much quantitative blood loss (QBL) has occurred, saturated items are weighed and the weight is converted to volume. For example, 1 kg of weight equals 1,000 ml of blood loss.

Level of consciousness and neurological changes  – Blood loss and its consequences can cause agitation, restlessness, confusion, dizziness, faintness, and lethargy. Any change in the patient’s neuro status or LOC should be cause for concern and warrant further investigation.

Vital signs – Keep a close eye on vital signs with frequent monitoring – every five to fifteen minutes is common in cases of suspected or confirmed hemorrhage.

Skin signs – Extensive blood loss can cause the patient to have pallor and/or clammy skin.

Urine output – Decreased urine output is a sign of poor tissue perfusion, which is a consequence of hypovolemia secondary to blood loss.

Emotional state – The patient is likely to be frightened or confused about what is happening.

T: What tests are utilized for a patient with postpartum hemorrhage?

Labs you may see ordered include CBC, coagulation panel, and type & crossmatch (in case blood products are needed). In addition, an ultrasound may be utilized to check for retained tissue and visualize the uterus.

T: What treatments are utilized?

The key treatments for postpartum hemorrhage are aimed at addressing the underlying cause to avoid further blood loss. 

• Fundal massage – Massaging the uterus helps it to contract, which provides mechanical hemostasis and reduces bleeding. To perform this intervention, place one hand above and below the fundus in a cup formation and massage until tone is restored. Note that fundal massage is not performed on a firm uterus, only a soft or “boggy” uterus.
• Medications – Uterotonic medications such as oxytocin and misoprostol help the uterus contract. 
• Intrauterine devices – A balloon device may be utilized to tamponade bleeding, while a low-level vacuum device encourages the uterus to contract.
• Volume replacement – Some patients may need volume replacement to maintain adequate cardiac output. This could be IV fluids, blood products, or both.
• Correct coagulopathy – Blood products and/or clotting factors can be utilized to correct clotting abnormalities.
• Surgery – In cases where bleeding is not controlled by less-invasive procedures, surgery may be indicated. These can include uterine artery embolization, repair of lacerations, removal of retained tissue, and even hysterectomy.

E: How do you EDUCATE the patient about postpartum hemorrhage?

Even in an emergency, education is key. Explanations of what is happening in the moment can go a long way toward lessening the patient’s (and family’s) anxiety. Once the acute event has passed, and the patient is receptive to teaching, key things to include in your education plan are:

• Bleeding should lessen over the next several weeks.
• The signs of delayed or secondary hemorrhage – heavy bleeding that saturates a peripad within an hour, clots larger than an egg, feeling faint or dizzy
• Encourage rest and gradual return to prior activity levels
• If the patient has been prescribed iron supplementation, teach them that it can cause dark stools and that liquid formulations should be taken with a straw to avoid discoloration of the teeth
• When to call the doctor – new signs of bleeding, being unusually fatigued, a fast heart rate, worsening abdominal pain

If this article helped you feel more confident about recognizing and managing postpartum hemorrhage, then you may be interested in more maternal-newborn topics. You can check them out here!

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References:

Berens, P. (2025). Overview of the postpartum period: Normal physiology and routine maternal care. UpToDate. https://www.uptodate.com/contents/overview-of-the-postpartum-period-normal-physiology-and-routine-maternal-care?sectionName=Patient%20education&search=postpartum%20hemorrhage&topicRef=6710&anchor=H38&source=see_link#H38

Cleveland Clinic. (2024, November 12). Postpartum Hemorrhage (PPH): Causes, Risks & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/22228-postpartum-hemorrhage

Crean, H. (2019, November 15). Postpartum Nursing Care. Wild Iris Medical Education. https://wildirismedicaleducation.com/blog/postpartum-care

Elsevier. (2020, January 30). Assessment: Postpartum Patients (Maternal-Newborn) – CE. Elsevier. https://elsevier.health/en-US/preview/reproductive-health/assessment-postpartum-patients-ce

Ignite Healthwise, LLC Staff. (2024, April 30). Postpartum Hemorrhage: Care Instructions. Healthwise. https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.postpartum-hemorrhage-care-instructions.acn1714

Watkins, A. (2023). Postpartum Haemorrhage and Fundal Massage. Ausmed. https://www.ausmed.com/learn/articles/postpartum-haemorrhage

World Health Organization. (2023). Methods of assessing postpartum blood loss for the detection of postpartum haemorrhage: evidence-to-decision framework. In WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage [Internet]. World Health Organization. https://www.ncbi.nlm.nih.gov/books/NBK598973/

Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2025). Postpartum Hemorrhage. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK499988/

Last Updated on May 8, 2025 by Maureen Osuna, MSN, RN