When to call

Call your local emergency number (999 in the UK and Ireland, 911 in the US and Canada, 000 in Australia, 111 in New Zealand), or go straight to a maternity unit, if you are bleeding after birth and:

the bleeding suddenly gets heavier, or is gushing
you feel faint, dizzy, or have a pounding or racing heart

The HSE lists exactly that combination as needing emergency treatment. ACOG's practical threshold is "soaking through two pads an hour for more than 1 to 2 hours," and it adds low blood pressure, pale or clammy skin, confusion, rapid heart rate, and pain or swelling near the vagina or perineum to the list of signs to call about immediately.

Contact your midwife, GP, obstetrician or maternity unit urgently — the same day — if:

your bleeding is getting heavier rather than lighter
you are passing clots
the blood smells bad or unusual for you
you start to feel unwell, shivery, achy, or have a temperature over 38°C

The HSE lists these as the warning signs of secondary postpartum haemorrhage. Treatment is usually antibiotics, and it works — but only if you make the call.

The timing everyone gets wrong

Postpartum haemorrhage is filed in most people's heads as a delivery-room event. It often is. But the RCOG defines two kinds, and the second one happens after you are home:

Primary PPH: losing 500 ml (a pint) or more of blood "within the first 24 hours after the birth."
Secondary PPH: "abnormal or heavy vaginal bleeding between 24 hours and 12 weeks after the birth."

ACOG says the same thing from the other side of the Atlantic: postpartum haemorrhage "usually happens within 24 hours of delivery. But it can occur up to 12 weeks later." The HSE, which uses a six-week window for secondary PPH, calls it "delayed PPH".

Twelve weeks. That is the number worth remembering, because it means bleeding that suddenly gets heavier at week five is not you imagining things, and it is not a period arriving early until someone has checked.

How much bleeding is too much

The RCOG grades primary PPH by volume: "minor, where you lose 500–1000 ml (one or two pints), or major, where you lose more than 1000 ml (more than two pints)." Your midwife is trained to estimate this, which is why the HSE says simply: "Your midwife is trained to know if you are bleeding heavily."

At home, nobody is measuring millilitres, so use ACOG's pad rule instead, and use the direction of travel. Lochia should get lighter. Bleeding that reverses course is the signal.

What causes it

For primary PPH, ACOG names the commonest cause: "uterine atony. Uterine atony happens when the muscles of the uterus do not contract normally. Without normal contractions, blood vessels do not tighten after delivery." It also lists retained pieces of placenta, blood clotting disorders, and tears in the uterus, cervix or vagina.

Secondary PPH has a narrower list. The HSE gives two causes: "an infection – usually in the lining of your womb (endometritis)" and "some placenta remaining in your womb after the birth (retained placenta)." The RCOG agrees that secondary PPH "is often associated with infection in the womb", which is why fever, smell and pain sit alongside the bleeding on the warning list.

Who is at higher risk

The HSE lists, among others: a previous PPH, a BMI of 35 or higher, a bleeding disorder, taking blood thinners, anaemia, four or more previous babies, being over 40 with a first baby, previous caesarean, placenta praevia, high blood pressure or pre-eclampsia, and twins or more. Labour factors include caesarean birth, retained placenta, induction, episiotomy, assisted vaginal birth (forceps or ventouse), a baby over 4 kg, labour lasting more than 12 hours, and general anaesthetic.

NICE's postnatal guideline (NG194) adds two factors that make the consequences of a secondary PPH worse rather than making it more likely: anaemia, and weighing under 50 kg at the booking appointment.

Most people with risk factors never have a PPH. The HSE says so directly. The point of knowing them is that if several apply to you, the RCOG and HSE both recommend giving birth somewhere a transfusion is available.

What prevention looks like

One intervention does most of the work. The RCOG: "If you have a vaginal birth, you should be offered an injection into your thigh just as the baby is born to help reduce blood loss. This injection helps the placenta to come away from the womb." That is oxytocin, and it is offered as standard. If you are anaemic, both the HSE and NICE point to treating that in pregnancy, because starting from a low haemoglobin makes any bleed harder to tolerate.

What treatment involves

For primary PPH, the HSE describes the sequence: breastfeeding if possible, firm rubbing of the lower tummy to help the womb contract, another injection, a drip into a vein, a catheter into the bladder, frequent observations and blood tests. If the bleeding continues: medicine through a drip, a transfusion, and sometimes theatre to find the cause, insert a balloon into the womb, or repair a tear. Hysterectomy is a last resort and is rare.

The HSE also warns about something that is frightening at the time and worth expecting: "When you are getting treatment, more staff may come into the room quickly. Your partner may be asked to leave for a few moments." That is a normal response, not a sign things have gone catastrophically wrong.

Secondary PPH is usually treated with antibiotics. The HSE says you may need to return to the maternity unit if the bleeding is very heavy or continues after antibiotics, where you may have antibiotics through a drip and a scan to check for retained placenta, and occasionally an operation to remove it. Your baby can stay with you and you can keep breastfeeding.

Afterwards

Losing a lot of blood leaves a mark. The HSE: "Losing a lot of blood after you give birth can make you feel very tired and weak," and a doctor "may advise that you take iron tablets for a few weeks." The RCOG describes prolonged fatigue and anaemia needing iron treatment and sometimes transfusion. You should also be given medicine to prevent blood clots and offered a hospital follow-up.

The psychological part is real and often neglected. The HSE asks you to contact your GP, midwife or obstetrician if you continue to have upsetting thoughts, flashbacks about the birth, increased anxiety or problems sleeping, because those are symptoms of PTSD "and they can be treated with the right support."

If you are planning another pregnancy, the HSE notes that a previous PPH increases the risk of another, and that care usually includes consultant-led appointments, an iron supplement, and a drip sited during labour. That is planning, not alarm.

Postpartum Haemorrhage