Postpartum haemorrhage: a case-based approach

The case: bleeding after the birth

Imagine a woman who has just given birth to a healthy baby in hospital. Soon after the placenta comes away, the midwife notices she is bleeding more heavily than expected, with blood soaking through pads quickly. The woman starts to feel faint, her heart races, and she looks pale. In the teaching setting, this picture suggests a postpartum haemorrhage — losing a large amount of blood in the first 24 hours after birth (called primary), or sometimes between a day and several weeks later (called secondary). The key teaching point is that heavy bleeding after birth can worsen fast, so it is treated as an emergency. In hospital, midwives and doctors act immediately together, and losing this much blood is never something to wait on.

Why it happens: the common causes

There are four main reasons for heavy bleeding after birth, sometimes remembered as the "four Ts". The most common is the womb not contracting firmly enough after birth, called tone — normally the womb squeezes down to close off the blood vessels where the placenta was attached. The second is tissue, where part of the placenta stays behind and stops the womb clamping down. The third is trauma, meaning a tear or injury to the birth canal or womb. The fourth is thrombin, meaning a problem with blood clotting. Some women are at higher risk, for example after a long labour, a large baby, twins, or previous heavy bleeding. Knowing the cause matters because each is treated differently, and finding it quickly is part of the emergency response.

The emergency response in hospital

When postpartum haemorrhage happens, the maternity team responds fast and works as a group. They call for extra help, check the woman's pulse and blood pressure closely, and give oxygen and fluids through a drip. A very common first step is to help the womb contract, by rubbing the top of the womb firmly and giving medicines that make it squeeze down. The team looks for the cause — checking whether the placenta is complete, examining for tears, and taking blood tests including clotting. A blood transfusion may be needed to replace what has been lost. If bleeding continues, further treatments or an operation can be used. This teamwork, done quickly and calmly, is why most women recover well even after a serious bleed.

After the bleeding is controlled

Once the bleeding is under control, the focus turns to recovery. The woman is watched closely for a while to make sure the bleeding does not return and that her blood pressure and pulse stay stable. Losing a lot of blood often leaves people feeling very tired, dizzy and short of breath for some time, because of a low blood count called anaemia. Iron tablets, and sometimes a transfusion, help the body rebuild. Feeding the baby, resting, eating well and gentle activity all support recovery. The team explains what happened and answers questions, which is important, as a frightening experience can affect how a woman feels emotionally. Follow-up checks make sure recovery is on track and give a chance to discuss any worries for the future.

Warning signs to know at home

Most heavy bleeding happens in hospital, but bleeding can occasionally become heavy in the days or weeks after going home, called secondary postpartum haemorrhage. It is normal to bleed for a few weeks after birth, gradually getting lighter. Seek urgent help if the bleeding suddenly becomes much heavier, if you soak a pad in an hour or pass large clots, if you feel faint, dizzy or your heart is racing, or if the blood smells offensive or you have a fever, which can signal infection. Feeling very unwell, breathless or unusually pale also needs urgent attention. Trust your instincts: if something feels seriously wrong, get help straight away rather than waiting to see if it settles.