Postpartum haemorrhage (PPH)

Contents

• Recovering from the unexpected

• What is a postpartum haemorrhage (PPH)?

• What causes a PPH?

• Contact maternity triage, their number is at the bottom of this leaflet

• What happens during a PPH?

• After your PPH has stopped

• What to expect: physical recovery, tests and follow-up

• Iron in the body

  • Effects of iron deficiency anaemia

  • Treatment

• Blood transfusion

• Eating for iron

• What to expect: breastfeeding

• What to expect: emotional recovery

• Talking about your birth

• Risk of clots in your blood vessels

• Do I need follow-up after a PPH?

• How to cope

• Families with older children

• Will I have another PPH during my next birth?

• When someone you love has had a PPH

• Contact Details

• Further Resources

• References

Recovering from the unexpected

This leaflet is a resource for you following a postpartum haemorrhage (PPH). You may be left with questions or wonder why you are taking longer to recover from your pregnancy. Try not to compare yourself and your recovery to friends / family.

This leaflet will help to guide you through your recovery. It will provide general information about:

• what a PPH is

• why it happens

• what to expect; and

• how it affects your recovery.

It will also provide information about answers to your questions or extra support, if needed. This leaflet may cause some distress, please do talk to your midwife if you have any questions or need more support.

What is a postpartum haemorrhage (PPH)?

PPH is heavy bleeding after birth.

It is normal to lose some blood during and after a birth. During pregnancy, the amount of blood you have in your body almost doubles. So, some blood loss during birth does not cause you any problems. However, if you lose more blood than normal, you may feel tired and weak. You may also find that recovering from the birth can be more difficult.

Midwives and doctors will usually say that you have had a PPH if you lose more than 500ml of blood (half a litre) following birth. Losing more than 1000ml after birth would usually be considered a “major” PPH. The amount of blood loss is not really as important as how the blood loss affects you. Some women / birthing people may lose more blood and feel fine, while others might lose less blood and be quite affected by it.

There are two types of PPH:

• Primary PPH is heavy bleeding within the first 24 hours following the birth.

• Secondary PPH is abnormal vaginal bleeding after 24 hours and up to 12 weeks after the birth.

What causes a PPH?

A PPH can happen unexpectedly, without any good way to predict that they would happen. Around 5 in 100 women / birthing people will lose around 500mls of blood after giving birth. Major PPH is much less common. They happen in approximately 6 in 1000 women / birthing people.

Your doctor will discuss with you the possible reasons for your PPH. They will explain where possible what happened. They will also answer any questions that you or your birth support person may have. If you think of any questions at a later date you can discuss these with your midwife. You can also contact our Birth Afterthoughts service. Telephone numbers are listed at the end of this leaflet.

There are things that can make a PPH more likely to happen. Some risk factors include:

• Having pre-eclampsia or high blood pressure in pregnancy.

• Being pregnant with twins or triplets.

• Having a BMI (body mass index) more than 35.

• If you had a condition called polyhydramnios (too much amniotic fluid).

• Having a long labour (more than 12 hours).

• Having a large baby (more than 4kg or 9lb).

• Forceps or ventouse / kiwi (suction cap) delivery.

• Having a labour that has been induced / augmented with oxytocin.

• Delivery by caesarean.

• Having had a PPH in a previous pregnancy.

• Blood clotting problems, or are taking blood-thinning medication.

• Delay in delivery of your placenta (retained after birth). Or if pieces of the placenta or membranes stay inside the uterus after delivery.

• If you have a condition with your placenta that affects how your placenta is attached to your uterus. Such as placenta acreta or increta.

Sometimes excessive bleeding can come from a more serious tear or cut to your perineum. This is the area between your vagina and your anus (back passage). Depending on the type and size of the tear, it may need to be repaired with stitches.

A secondary PPH is most often caused by retained products or uterine infection. Retained products include a small part of the membranes or a small part of the placenta. The membranes are what surround your baby when it is in your uterus (womb). If small parts of either of these remain in your uterus they can cause bleeding or infection. Sometimes it may not be possible to tell if your placenta or membranes were complete. Your midwife or doctor will tell you if there is any concern that you may have retained products.

Risk factors for uterine infection can include:

• Caesarean birth.

• Premature rupture of your membranes (PROM). When your waters break more than 24 hours before your baby is born.

• Retained products.

It is important to tell us straight away if you are feeling unwell or you have:

• flu type symptoms;

  • Fever

  • Feeling hot and cold

  • Shivering

  • Extreme tiredness

  • Reduced appetite

• smelly blood loss (blood loss with an offensive smell)

• severe abdominal pain

• chest pain and / or breathing very fast.

Contact Maternity Triage, their number is at the end of this leaflet.

What happens during a PPH?

If you have experienced a PPH you may have questions about the steps that were taken to stop the bleeding. A PPH often leads to a busy environment, as other members of staff come to help. You may feel dizzy, light-headed, faint, or sick. Some of the steps commonly taken to treat a PPH are:

• Uterine massage to help the uterus contract. This may be uncomfortable. A midwife or doctor will place their hand on your tummy, and rub your uterus (womb) to help it contract.

• Drugs given by injection into your thigh, or through a canula (a small plastic tube in your vein). This is to help your uterus contract.

• An examination of the vagina and perineum (the area between your vagina and your bottom). This is to see if any stitches are needed.

If the bleeding does not stop, further steps may include the following. You may or may not have had all of these steps. Most bleeding stops with a few simple measures.

• Oxygen given to you by face mask.

• Additional drugs given by injection and / or through a canula (a small plastic tube in your vein). There are various drugs that can help your uterus contract. You may have received one or several. These drugs can sometimes make you feel sick, give you a nasty headache, or cause diarrhoea (loose and watery poo).

• A urinary catheter to keep your bladder empty and help your uterus contract.

• The doctor may ask for small tablets (misoprostol) to be inserted into your anus (back passage). This is very effective to help stop bleeding.

• With severe bleeding, a midwife or doctor may need to perform internal procedures. They would place one hand inside your vagina, and the other hand on your tummy to help stop the bleeding. We understand that this can be distressing for you, and also your birthing support person. This is an emergency procedure to stop severe bleeding, and to create more time to stabilise you. It is often used before you are transferred to theatre, or into the hospital from home. This is called “bimanual compression” it can be painful, but this works very well in an emergency.

• A “manual removal” of the placenta. If your placenta has not delivered, or the cord has snapped, it may need to be removed manually. This is usually done in the operating room with anaesthesia. Rarely, if the bleeding is very serious, there may not be time for anaesthesia. Manual removal is performed by a doctor, and it can be a very painful procedure.

• In some emergency situations surgical procedures are needed. Your doctor will discuss these with you if you have experienced this.

We understand that this could have been a very distressing time for you. You can speak with your midwife or doctor to answer any questions that you may have. You can also speak to our specialist midwife at Birth Afterthoughts for support. Their number is at the end of this leaflet.

What happens after your PPH has stopped?

If you had a PPH you may need to stay in hospital for longer than you had planned. You may have stayed on labour ward longer, or not returned to labour ward until you were medically stable. This is so you are able to receive one to one care.

If you had a PPH at home, you may need to transfer into hospital, and you may need to stay for a day or two. This will depend on how much blood you lost and if the bleeding has been well controlled. The length of your stay will depend on your individual circumstances.

It usually takes longer to recover from a birth with a PPH than a birth with normal blood loss. Remember to listen to your body and to speak with your midwife or doctor if you have any worries or concerns. We understand that a PPH can be very frightening for you and your birth support person. You may have questions for your midwife, doctor, or at Birth Afterthoughts. There is a section at the end of this leaflet for you to make notes.

What will happen after my PPH (physical recovery, tests, and follow-up)?

• Iron in the body

  Iron is in every cell in your body and it plays many important roles in your overall health.

  Your body uses iron to make haemoglobin. Haemoglobin is a part of your red blood cells and it carries oxygen through your body. If you do not have enough iron, your body makes fewer and smaller red blood cells. This condition is called iron deficiency anaemia. When this happens, it is harder for your body to get enough oxygen. This can leave you feeling breathless, tired and weak. It is very common to have iron deficiency anaemia after you have had a PPH.

  Your midwife may want to do a blood test to check your haemoglobin. This will help your midwife or doctor understand how your body is coping with the blood loss. Helping them to decide what treatment to recommend to you.

• Effects of iron deficiency anaemia

  Iron deficiency anaemia can affect how you feel. Anyone who has given birth can expect to feel tired and possibly overwhelmed. Adding iron deficiency anaemia to recovering from birth can make your recovery challenging. When your iron is low, it is normal to:

  • Feel weak and get tired more easily

  • Feel dizzy

  • Suffer from low mood, or feel upset

  • Have headaches

  • Look pale

  • Feel out of breath

  • Have trouble focusing or concentrating.

  To treat these symptoms, it is important to rest and to listen to your body. Speak with your midwife if you have any worries or feel unwell. You can also contact Maternity Triage for more advice. Their number is at the end of this leaflet.

• Treatment for iron deficiency anaemia

  Your midwife or doctor may recommend taking iron supplements following a PPH. When iron levels are already low, it can be difficult to get enough iron from your diet alone. Iron supplements should help to get your iron levels back to normal. This will help you start to feel like yourself again. Most women / birthing people will not be on multiple doses of iron. If you are, this will only be for a short time. Speak to your midwife or doctor if you have any questions.

  In some cases, there may be some side effects, such as an upset stomach or constipation.

  It is safe to breastfeed whilst taking iron supplements. They do not increase the amount of iron that is in your breast milk.

  Follow these tips to avoid side-effects and to get the most out of your iron supplements.

  • Try taking iron in smaller doses more often throughout the day; or

  • Try taking your prescribed dose of iron every other day. Taking iron one day and then not the next, and so on.

  • Try taking your iron supplement before bed at least an hour after your last meal.

  • Do not take your iron supplement with calcium, this includes eating or drinking dairy. Some medication also contains calcium (calcium pills or antacids like Gaviscon). Calcium binds to iron and stops your body from absorbing it effectively.

  • Do not drink coffee or tea within an hour of taking iron supplements.

  • Eat high fibre foods, such as fruit and whole grains (such as bran) to prevent constipation. Another option is to take a stool softener, such as lactulose. Speak to your midwife if you suffer from constipation.

  • Try taking iron with a glass of orange juice (vitamin c helps absorption).

  • Drink plenty of fluids.

  If your iron levels are very low, iron supplements may not be enough to increase your body’s iron levels. In this case, you may be offered iron by injection or through a canula (a small plastic tube in your vein). Your midwife or doctor will discuss this with you, if they recommend this. For more information, please read the Intravenous (IV) iron infusion leaflet. 

• Blood transfusion

  You may have received a blood transfusion during, or sometime after your PPH. A blood transfusion is given through a canula (a small plastic tube in your vein). In an emergency situation with a significant PPH, you may have received a blood transfusion straight away. If your blood loss was significant this may have been necessary for your safety. It takes time for your body to make new red blood cells to replace the ones you lost during the haemorrhage. A blood transfusion gives your body new blood right away.

  If your iron levels are very low after birth, we may recommend that you have a blood transfusion. It will help to speed-up your recovery and reduce your feelings of weakness and fatigue (extreme tiredness).

  Blood donations in the UK are carefully screened for infections. Blood given to you will be matched to your own blood group, it will be double checked at your bedside by two midwives or doctors. If you have a blood transfusion there is a very small risk of an allergic reaction. Symptoms of this could include:

  • a temperature

  • chills; or

  • a rash.

  Your midwife will carefully monitor your observations to make sure you are well. Chances of getting an infection from a blood transfusion is less than 1 in 1 million. There is a very small risk of other complications after a blood transfusion, such as:

  • a severe allergic reaction

  • difficulty breathing due to fluid overload

  • incompatibility due to red cell antibodies.

  The risks will be explained before you have a transfusion, unless this is not possible. For example, if you need an emergency transfusion. If you have any questions, speak with your midwife or doctor.

• Eating for iron

  Even if you are taking iron supplements, your diet is an important source of iron. Some women or birthing people who have had a PPH say that they were incredibly hungry in the weeks that followed. Some will even eat and crave foods they would not normally eat. It is easy to find a list of iron-rich foods online. Some sources are listed at the end of this leaflet.

  Here are a few tips to quickly and easily increase the iron content of food you may already be eating.

  • If you eat meat, darker meats like beef, lamb, duck or venison have the most iron.

  • Some seafood like prawns, oysters and octopus have a lot of iron.

  • Eat salads made of spinach instead of lettuce.

  • Consider adding pumpkin seeds, chickpeas and nuts to a salad to make an iron-rich meal.

  • Nuts and dried fruits, such as apricots.

  • Lentils have more iron than beef. Add lentils to a soup or stew to boost the iron content.

  • Try almond butter instead of peanut butter. Two tablespoons of almond butter has as much iron as a serving of chicken.

  • Avoid eating dairy (milk, yogurt, cheese) with the iron rich foods. The calcium in dairy can make it harder for your body to absorb the iron in the other food.

  To help your body absorb the iron, do not forget to add foods with vitamin C to your meal. Fruits and vegetables containing vitamin C include:

  • kiwi fruit

  • oranges

  • potatoes

  • cauliflower

  • broccoli

  • brussels sprouts

Can I still breastfeed after a PPH?

After a PPH most women / birthing people find that they can breastfeed successfully. You might not have been able to feed your baby as soon as you had wanted or had as much skin to skin as you had hoped. As soon as you feel able, staff can support you with skin to skin and helping your baby to breastfeed.

If you feel able you can do some hand expressing to stimulate your milk. Do not worry if you are not ready to do this to start with. Ask for help if you need it to get started.

It is normal to feel as though you only have small amounts of milk in the first couple of days. Don’t worry this will increase over the first week, after the birth of your baby. 

For more help on how to tell if breastfeeding is going well, please read this UNICEF leaflet.

You may want to consider colostrum collection in any future pregnancy. This can be started after 36 weeks of pregnancy. More information is available in the Expressing colostrum during pregnancy leaflet.

Other useful information leaflets to support feeding your baby are available here.

How might I feel emotionally after my PPH?

It can be upsetting when things do not go as planned during your baby’s birth. Talking about it can help. You may like to talk to the health care providers who looked after you during your PPH. You can do this while you are in hospital or you may like to wait until later when you feel better. Finding out if there was a reason for your PPH and what treatment you had, can also help with planning your next baby. Do not be afraid to share your feelings with your midwife and your support people, and to ask for extra support. If you feel overwhelmed, midwives can also help you to problem solve how to access extra help.

The “baby blues” and postnatal depression can affect anyone who has had a baby. You may be more likely to have postnatal depression after a PPH. Below are some of the symptoms of postnatal depression and iron deficiency anaemia. You will see some overlap in the symptoms for each, as the symptoms can be very similar. It can be hard to tell what you are feeling, but talking to your midwife can help. They can help and support you if you are suffering from postnatal depression.

Who can I talk to about my birth?

During your stay in hospital, you can talk to us at any time and ask any questions you may have. You can speak with your community midwife once you have gone home.

It can be important for you and your family to go over your birth and the experience of the PPH. You may have questions about the birth, days or even many months or a year or two after the birth of their baby. We are able to offer you and / or your support person a debrief with a specialist midwife. This is through our Birth Afterthoughts service.

They will review your notes with you, and help to answer any questions that you may have when you are ready. Some women / birthing people may choose not to talk about their birth experiences, as it is too soon after birth. You can always use our Birth Afterthoughts service when the time is right for you. Their contact details are at the end of this leaflet.

Risk of clots in your blood vessels

A PPH increases your risk of having a blood clot (a venous thromboembolism (VTE)) after birth. Moving around and drinking plenty of water can help prevent a blood clot forming. You may also be advised to take medication to reduce your risks. This will depend on your individual circumstances. Your midwife or doctor will discuss this with you. More information on VTE is available in the Reducing the risk of VTE in pregnancy and the postnatal period leaflet.

Do I need follow-up appointment after a PPH?

You will have a routine check-up with your GP about 6 weeks after giving birth. Call Maternity Triage (their number is at the end of this leaflet) for advice if:

• Your bleeding increases.

• You need to change your pad every 1 to 2 hours.

• You pass clots of blood.

• Your bleeding changes and becomes bright red in colour.

• You have a high temperature (more than 37.5°C).

• You have pain, redness, or swelling in your legs.

• You feel short of breath while resting.

• You feel dizzy.

• You feel more tired or emotional than you expect.

• You feel unwell.

• Your bleeding becomes very smelly.

How to cope afterwards

You must listen to your body, sometimes tiredness can come on very unexpectedly. Resting will help you to recover. It can be hard to rest when you are used to being a busy and active member of your family. Taking the time you need to rest is very important. Do not be afraid to ask for help from friends and family.

Here are a few ideas that might help:

• Avoid having too many visitors at once, as it can be very tiring.

• Have reasonable expectations. Taking a shower can count as a big accomplishment.

• Accept any offers of help with food or housework, from family or friends.

Families with older children

If you have older children it can be especially challenging to get the rest you need. You can be creative in coming up with ways to spend time with your older children and still get the rest you need. Invite them into bed to play and spend time with you and the new baby. Here are some ideas.

• Have “picnics” in bed or on the bedroom floor with older children so that you can still rest.

• Have movie nights in bed with the whole family.

• Invite another family member to come and read stories to you and your children. This could be a special kind of family story time.

Will I have another PPH during my next birth?

If you have a PPH with one birth, your chances of having one again are a little higher. This is in comparison to someone who has never had a haemorrhage. Keep in mind that the overall risk of a PPH is still low.

If you are taking iron supplements, it is a good idea to plan to have your haemoglobin levels checked about three months after your birth. You can ask your GP for this test when your baby is three months old.

In your next pregnancy, it will be important to make sure your iron levels are healthy. This will lower your risk of becoming anaemic if you have another PPH. Your midwife may also recommend that you plan to have an injection of oxytocin right away after your next birth. This is called “active management” of the birth of the placenta, and it may help to prevent a PPH. Make sure you tell your midwife in your next pregnancy that you had a PPH with a previous birth.

When someone you love has had a PPH

Supporting a woman / birthing person after a PPH can be challenging. Recovering from PPH usually takes longer to recover after the birth. They may need to be encouraged to rest. There are many things you can do to help such as cleaning, cooking, and taking care of any older children. If you are concerned that they are having a hard time emotionally or physically, encourage them to speak to their midwife. And remember to take care of yourself.

Sometimes a PPH can be a traumatic or distressing experience for everyone involved. It is normal for support people to experience distress or difficulty after a PPH. It can be confusing to feel happy and excited about the new baby and also afraid and upset after an emergency happened. It can be hard to watch your loved one struggle when they are not feeling well. You might find it helpful to talk about your feelings. Do not be afraid to ask for help. You can always ask questions of the midwife caring for your family. You can also access our Birth Afterthoughts service. Their details are at the end of this leaflet.

Welcoming a new baby is exciting but can also be overwhelming even at the best of times. Remember, recovering after a PPH is not the same as recovering from a birth with normal blood loss.

Try to have realistic expectations of yourself and your loved one.

Contact details

• Contact Maternity Triage on 01227 206737 for help and advice.

• If you are more than 42 days after the birth of your baby call 111 for advice or see your GP. If you are very unwell or have very heavy bleeding call 999.

• Contact the Birth Afterthoughts service if you have any unanswered question about the birth of your baby. You can call or email 'Birth Afterthoughts' to arrange an appointment.

  • Email

  • Telephone: 01227 864152 (open 9am to 3.15pm)

Further resources

Some information in this leaflet has been reproduced with the kind permission of the association of Ontario midwives.

• Tommy's. Your mental health after the birth.

• Birth Trauma Association
  Telephone: 0203 621 6338

• Birth Trauma Association. Father and partners: coping with a traumatic birth.

• Tommy's. Iron in pregnancy.

• Make Birth Better

• Not what we planned: two stories of birth and postpartum hemorrhage (Ontario Midwives patient video)

References

• Royal College of Obstetricians and Gynaecologists. Heavy bleeding after birth (postpartum haemorrhage). December 2016.

• Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage (Green-top Guideline No. 52).