Postpartum hemorrhage is heavy bleeding after birth, defined as a total blood loss of 1000 mL or more, or any loss with signs of low blood volume. It is a leading cause of maternal death, and most cases come from a uterus that does not contract well.
Key symptoms
- Heavy vaginal bleeding or large clots after delivery
- Dizziness, weakness or feeling faint
- Pale, cold, clammy skin
- Anxiety or confusion as blood loss grows
What you find on exam
- Soft, boggy uterus above the umbilicus
- Quantified blood loss by weighing pads and drapes
- Heart rate, blood pressure and shock index
- Inspect for tears of the perineum, vagina or cervix
Tests
- Blood count, type and crossmatch
- Coagulation tests and fibrinogen
- Bedside ultrasound for retained placenta or clots
- Work through the 4 Ts: tone, trauma, tissue, thrombin
Treatment basics
- Call for help, place two large IVs, massage the fundus and empty the bladder
- Oxytocin first, then methylergonovine, carboprost or misoprostol
- Tranexamic acid within 3 hours of birth
- Transfuse blood products, repair tears and remove retained tissue
- Balloon tamponade, embolization or surgery if bleeding continues
Red flags
- Heart rate higher than the systolic blood pressure
- Ongoing bleeding despite massage and oxytocin
- Oozing from IV sites suggesting a clotting disorder
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Sources: NCCPA PANCE Content Blueprint; NCSBN 2026 NCLEX-RN Test Plan; NREMT psychomotor skill sheets (EMT and Paramedic). Written by Making Synapses. Making Synapses is not affiliated with these organizations.