Which of the following conditions in a postpartum client is most likely to cause hemorrhage?

The journey of pregnancy, the joy of having your baby, the lifetime of moments that lie ahead, you are eager to enter motherhood, but then there comes the unexpected postpartum bleeding. Is it normal? or is it hemorrhage?

Texas children’s Dr. Karin Fox answers six common questions about postpartum bleeding.

Q: How much postpartum bleeding should I expect after delivery?

After giving birth, some postpartum bleeding will typically continue for two to three weeks. It should be like a period or less, and gradually resolve over time. If you develop a fever, start passing clots or soak through several pads within an hour or two, you need to contact your physician, especially if you start experiencing dizziness, shortness of breath or heart palpitations.

Q: Does breastfeeding help with postpartum bleeding?

Breastfeeding helps the uterus contract and stay firm, and may help reduce the risk of uterine atony (when the uterus fails to contract after delivery).

Q. How do I know if I am experiencing hemorrhage or regular bleeding?

The American College of Obstetrics and Gynecology recently redefined postpartum hemorrhage as any bleeding greater than or equal to 1,000 milliliters (1 liter) at the time of delivery, as well as changes in vital signs.

Most commonly, we see postpartum hemorrhage within the first 24 hours, but some women may have delayed postpartum hemorrhage. This can occur as late as several weeks after delivery. Any bleeding that is very heavy should prompt a call or visit to your provider.

Q: How do I know if I am at risk of postpartum hemorrhage?

Every woman is different and certain health conditions may increase your risk of hemorrhage. Below are examples of health conditions that may influence your risk of postpartum hemorrhage. 

• Conditions such as multiple uterine fibroids can increase your risk for bleeding at the time of delivery.
• Anything that leads to uterine atony (failure of the uterus to contract after delivery), such as developing an infection during labor, having uterine distension due to multiple gestation (twins, triplets), polyhydramnios (high amniotic fluid level) or a prolonged labor can increase your risks for bleeding.
• If you take anticoagulant because of a clot, like a deep vein thrombosis, have a history of a pulmonary embolism or have a mechanical heart valve, these also put you at an increased risk for hemorrhage.
• Any preexisting bleeding disorder, such as Von Willebrand disease, Factor VIII or IX deficiency could also increase your risk.
• Certain placental conditions, such as placenta accreta or placenta previa, are associated with heavier than usual bleeding.
• Women who refuse blood transfusions are also at an increased risk, not necessarily of having heavier than usual blood loss, but of complications due to refusal of blood replacement, if it is truly needed.

Q: What can I do to reduce my risk?

Avoid and treat anemia. Take iron regularly if you are instructed to do so.

Be transparent with your doctors if you’ve had postpartum hemorrhage in the past. If you or your family members have a bleeding disorder or if you notice bleeding before delivery, be sure to tell your provider. 

If your doctor recommends a cesarean delivery because your labor is prolonged, consider that an abnormally prolonged labor can increase your risk for infection and bleeding. Most importantly, if you experience excessive bleeding after birth, especially once you are home, you should see a doctor.

Q: Are you conducting any research with regards to obstetrical hemorrhage?

We are always looking for new techniques to stop bleeding. For example, we utilize combat gauze that contains special agents to help stop bleeding. We are consistently trying to innovate. We are conducting research into blood loss and better ways to tailor transfusions to provide the most advanced care for our patients.

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At the Pavilion for Women, we work very hard to provide the best care for every woman in labor. Before you even begin to labor, we take time to identify if you are at risk for heavier than usual bleeding, and remain vigilant throughout your labor and delivery for any sings of potential hemorrhage.

We strive to prevent postpartum hemorrhage whenever possible by avoiding unnecessary interventions, but also intervening when necessary in a timely manner.

Our robust blood bank allows us to provide care for patients with blood types that are difficult to match or who refuse blood for personal or religious reasons. The blood bank can provide red blood cells, plasma, platelets or other components that help stop bleeding.

The Pavilion for Women is the only hospital in Texas to have a “Center of Excellence” designation for obstetrical anesthesia. Our anesthesia and surgical teams are well trained with several simulated scenarios and are capable of responding to even the most complex cases.

Dr. Christina Davidson, Vice Chair of Quality and Safety, implemented a Maternal Early Warning System that empowers nurses to get a provider to the bedside within minutes to assess patients who have signs or symptoms of complications, like hemorrhage.

Several of our faculty actively participate in the TexasAIM Hemorrhage Collaborative. Where we learn how to recognize, respond to and treat postpartum hemorrhage.

We take pride in our multidisciplinary team approach to care, and our commitment to continued improvement and patient safety.

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When is postpartum hemorrhage most likely to occur?

Which factor puts a client at risk for postpartum hemorrhage?