Magazine article American Nurse Today

Secondary Postpartum Hemorrhage: Risk Factors, Assessment, and Intervention

Magazine article American Nurse Today

Secondary Postpartum Hemorrhage: Risk Factors, Assessment, and Intervention

Article excerpt

Jayne Kennedy, a 35-year-old, gravida 2, para 2, is admitted to the emergency department with heavy vaginal bleeding. Two weeks earlier, she'd delivered an infant by a repeat Cesarean section. Nursing assessment reveals a temperature of 102[degrees] F gestational diabetes mellitus (GDM), which occurred during both pregnancies. She's now presenting with a secondary postpartum hemorrhage.

Scenarios like this happen more often than you might think. Also called late or delayed hemorrhage, secondary postpartum hemorrhage occurs between 24 hours and 6 weeks postpartum. Typically occurring after discharge, it's the leading cause of readmission in postpartum patients. In contrast, primary (early) postpartum hemorrhage occurs within the first 24 hours after delivery.

Most postpartum patients aren't aware of the potentially life-threatening complications that can occur if bleeding goes untreated. In fact, postpartum hemorrhage (primary and secondary combined) is the leading cause of maternal morbidity in low-income countries and accounts for about 25% of maternal deaths globally. Fortunately, with appropriate diagnosis and management, catastrophic consequences can be prevented.

Defining postpartum hemorrhage

Postpartum hemorrhage refers to an estimated blood loss of 500 mL or more after delivery.Some experts add a hematocrit decrease of 10% or more to the definition.

Secondary postpartum hemorrhage can be hard to identify. A patient who's hemorrhaging may assume she's just having heavy--but normal--postpartum bleeding.


Infection and retained products of conception are the leading causes of secondary postpartum hemorrhage. Pelvic ultrasound may be done to detect retained placental fragments. Clinicians should suspect retained fragments in a patient with delayed lactogenesis.

Retained products of conception can lead to uterine atony--failure of effective uterine contraction after delivery. This condition accounts for 75% to 80% of postpartum hemorrhage cases. Risk factors include:

* an overly distended uterus caused by polyhydramnios, multiple gestation, or macrosomia

* uterine muscle exhaustion caused by rapid labor, prolonged labor, or high parity

* intraamniotic infection caused by fever or prolonged labor

* anatomic abnormalities, such as fibroids or placenta previa.

Uterine atony can be localized or affect the whole musculature.

Predelivery risk factors

The first step in preventing primary and secondary postpartum hemorrhage is to identify at-risk patients before delivery. Risk factors include:

* personal or family history of postpartum hemorrhage

* abnormal placentation

* placental abruption

* preeclampsia

* multiple gestation

* multiple parity

* precipitous labor

* chorioamnionitis

* polyhydramnios

* macrosomia

* uterine infection

* uterine inversion

* sickle cell anemia

* gestational diabetes

* obesity

* Asian or Hispanic ethnicity

* coagulation disorders. (See Role of coagulation disorders in postpartum hemorrhage (

In our opening scenario, patient Jayne Kennedy is at increased risk for postpartum hemorrhage because of her multiple parity and history of gestational diabetes.

Delivery and postdelivery risk factors

Identifying blood loss during and after delivery is crucial. Distinguishing secondary hemorrhage and heavy postpartum bleeding can be challenging. What's more, visual or estimated assessment of blood loss can be inaccurate.One study found healthcare providers underestimated postpartum blood loss during delivery by 21% to 28%. Implementing objective quantitative measurement of blood loss can lead to more accurate estimates. …

Search by... Author
Show... All Results Primary Sources Peer-reviewed


An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.