Understanding Postpartum Hemorrhage (PPH): What It Is, Why It Happens, and How It’s Treated
Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality worldwide. In the U.S., it accounts for approximately 11% of pregnancy-related deaths. Understandably, many people are frightened by the idea of hemorrhaging after birth. The good news is that, when quickly recognized and treated, PPH is often managed effectively—and most birthing people recover completely.
This article is here to explain what postpartum hemorrhage is, what causes it, how it’s treated, and how you can understand your individual risk.
What Is Postpartum Hemorrhage?
Postpartum hemorrhage is defined as excessive blood loss after the birth of a baby. There are two types:
Primary (Early) PPH: Occurs within the first 24 hours after birth.
Secondary (Late) PPH: Occurs more than 24 hours after birth, up to 6–12 weeks postpartum.
While some blood loss is normal during birth (typically around 500 mL after vaginal birth and up to 1000 mL after a cesarean), PPH is diagnosed when the bleeding exceeds these amounts or causes symptoms of low blood volume, such as dizziness, rapid heartbeat, low blood pressure, or fatigue.
Causes of Hemorrhage: The “Four Ts”
Clinicians often use the “Four Ts” framework to quickly assess and treat the source of postpartum bleeding:
Tone – Uterine atony (the uterus fails to contract after birth)
Most common cause (about 70–80% of cases)
A soft or “boggy” uterus allows excessive bleeding from the placental site
Tissue – Retained placenta or clots
Fragments of placenta or membranes left inside the uterus prevent full contraction
Trauma – Tears or lacerations in the cervix, vagina, or perineum
Can occur during rapid birth, instrumental delivery, or episiotomy
Thrombin – Coagulation disorders
Includes pre-existing conditions (e.g. von Willebrand disease), HELLP syndrome, or acquired clotting problems
Who Is at Risk?
While PPH can happen to anyone, certain factors may increase the likelihood:
Prenatal Risk Factors:
History of postpartum hemorrhage
Placenta previa or accreta
Multiple gestation (twins, triplets)
Polyhydramnios (excess amniotic fluid)
Anemia
Large baby (macrosomia)
First birth or high parity (5+ births)
Clotting disorders
Labor & Birth Risk Factors:
Long or rapid labor
Prolonged second stage of labor
Use of Pitocin (oxytocin)
Cesarean birth
Assisted delivery (forceps or vacuum)
Uterine overdistension
Chorioamnionitis (infection during labor)
Importantly, many cases of PPH occur in people with no known risk factors, which is why active management and monitoring are so important during and after birth.
Medications Used to Treat Hemorrhage
When hemorrhage occurs, medical providers act quickly using a stepwise approach, starting with the least invasive options and progressing as needed.
1. Uterotonics
– Medications that contract the uterus:
Oxytocin (Pitocin)
First-line treatment; given IV or IM
Stimulates uterine contractions to stop bleeding
Misoprostol (Cytotec)
Given rectally, orally, or sublingually
Often used when Pitocin is unavailable or ineffective
Methylergonovine (Methergine)
IM injection that causes strong uterine contractions
Contraindicated in people with high blood pressure
Carboprost (Hemabate)
IM injection used in severe cases
Contraindicated in people with asthma
2. Tranexamic Acid (TXA)
An antifibrinolytic that helps stabilize clots and reduce blood loss
Safe for most people and effective when used within 3 hours of bleeding onset
Increasingly recommended by the WHO and ACOG
Other Interventions
If medications alone don’t stop the bleeding, more advanced interventions may be necessary:
Uterine massage: Manual stimulation to help the uterus contract
Manual removal of retained tissue
Repair of lacerations: Suturing tears in the cervix, vagina, or perineum
Bakri balloon: A balloon device inserted into the uterus to apply pressure
Uterine artery embolization: Interventional radiology procedure to block bleeding vessels
Surgery: Including D&C (dilation and curettage) or, in extreme cases, hysterectomy (removal of the uterus)
How Common Is It—and Why Do People Still Die From It?
Postpartum hemorrhage occurs in about 1–5% of births globally, depending on location and access to care.
In the U.S., rates of severe maternal morbidity from PPH are rising, partly due to increasing cesarean rates, obesity, and chronic health conditions.
Black women in the U.S. are 3–4 times more likely to die from pregnancy-related complications, including hemorrhage, due to systemic racism, bias in care, and lack of timely intervention.
Globally, most maternal deaths from hemorrhage are preventable with access to basic emergency obstetric care. Delays in recognizing hemorrhage, poor access to blood transfusions, and lack of trained staff are key contributors.
Can It Be Prevented?
In many cases, yes. Here’s how providers help reduce the risk:
Active Management of the Third Stage of Labor (AMTSL)
Routine use of oxytocin immediately after birth
Controlled cord traction
Uterine massage
Close Monitoring in the First Hours Postpartum
Frequent fundal checks
Tracking bleeding, clots, and vital signs
Planning for High-Risk Cases
IV access in place during labor
Blood products available if needed
Skilled team ready for rapid response
Clients can advocate for:
Giving a thorough medical history, including clotting disorders or past hemorrhages
Asking about PPH protocols at their birth location
Having a doula or birth partner aware of early warning signs
Final Thoughts
While postpartum hemorrhage can be serious, most people recover fully—especially with quick, evidence-based care. Knowing the signs, risk factors, and treatment options can empower you to ask questions, build a skilled care team, and feel more confident going into birth.
If you’re pregnant and have concerns about PPH, bring them to your provider. You deserve respectful, responsive care—and your questions are valid.
References
American College of Obstetricians and Gynecologists (ACOG). (2017). Practice Bulletin No. 183: Postpartum Hemorrhage.
World Health Organization (WHO). (2012). WHO recommendations for the prevention and treatment of postpartum haemorrhage.
Main, E.K., et al. (2015). “Reducing maternal mortality from postpartum hemorrhage in California: Outcomes from the CMQCC initiative.” American Journal of Obstetrics & Gynecology, 212(3), 278.e1–278.e7.
Shakur, H., et al. (2017). “Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum hemorrhage (WOMAN trial): an international, randomized, double-blind, placebo-controlled trial.” The Lancet, 389(10084), 2105–2116.
Gungorduk, K., et al. (2013). “Comparison of the Bakri balloon tamponade with uterine packing for the management of postpartum hemorrhage.” Archives of Gynecology and Obstetrics, 288(3), 505–510
Creanga, A. A., et al. (2015). “Trends in pregnancy-related mortality in the United States: 1993–2006.” Obstetrics & Gynecology, 123(4), 639–649.
