Primary postpartum haemorrhage: heavy bleeding in the first 24 hours

Everyone bleeds after giving birth. The RCOG explains the blood mainly comes from where the placenta was attached and from any cuts or tears, is heaviest just after birth, and reduces over hours and days. The colour changes from bright red to brown over a few weeks. This vaginal loss is called lochia and usually stops by about 12 weeks, the RCOG says; the NHS says it often stops after 6 to 8 weeks but may last longer.

Postpartum haemorrhage is heavy bleeding after birth. The RCOG separates primary PPH, within 24 hours, from secondary PPH, between 24 hours and 12 weeks. Doctors sometimes use the term uterine atony for a womb that does not tighten well after the birth, one reason for primary PPH; the RCOG describes the measures used to encourage the womb to contract.

The RCOG says that even if some risk factors apply to you, most women with them do not have a haemorrhage, and most who do have no identifiable risk factors. Those at higher risk may be advised to give birth in a hospital setting with access to blood transfusion. The factors it lists are grouped below.

NICE intrapartum guidance compares two ways of managing the third stage of labour (from the birth of the baby to delivery of the placenta). Active management gives a uterotonic injection, clamps and cuts the cord and uses controlled cord traction; physiological management has no routine injection and waits for the placenta to be delivered naturally. NICE says that, per 1,000 women, about 68 would have a bleed over 500 ml with active management compared with about 188 with physiological management, and about 13 compared with 29 would lose over a litre. It advises that active management is associated with a lower risk of PPH or blood transfusion, and that if you ask for physiological management your level of risk is discussed and your choice supported.

The RCOG adds that if you are anaemic in pregnancy, iron supplements may reduce the likelihood of needing a transfusion, with iron by drip if you are very anaemic or cannot take tablets. After a vaginal birth you are examined for tears, and bleeding tears are stitched. If you are at high risk, you may be given additional medicines. Do not start iron or any other medicine unless a clinician advises it.

The RCOG says that if you are at home or in a midwifery unit your midwife calls for help and arranges transfer to hospital, and in hospital the midwife presses the emergency bell. It can be frightening to see people rush in, and staff should tell you and your partner what is happening. You may feel dizzy, light-headed, faint or nauseous.

The steps the RCOG lists first: massaging the womb through the abdomen, sometimes also vaginally; giving a second injection (or a first) to help the womb contract; emptying the bladder with a catheter; a drip with warm fluids after blood is taken; checking that all the placenta has come out, and removing any remaining pieces, usually in theatre under anaesthetic; and examining you for tears that need stitches. If you have lost more than 1,000 ml, senior staff are involved, with more medicines, oxygen, a second drip and possibly a blood transfusion or medicine to help clotting.

If bleeding continues you may go to theatre to find the cause. The RCOG lists a balloon inserted in the womb to press on bleeding vessels (usually removed the next day), an abdominal operation, uterine artery embolisation by a radiologist, and, very occasionally, a hysterectomy. You may go to intensive care or high dependency afterwards. These are decisions made by senior clinicians in the moment; you are consented as far as is possible, and your preferences about blood products should be recorded in your notes well before birth.

The RCOG says you may need a longer hospital stay, and that after a PPH you may be tired and anaemic and need iron treatment, with full recovery taking a few weeks. Your GP may offer a blood test at 6 to 8 weeks to check your blood count. You can still breastfeed. After a PPH the risk of blood clots is increased, so you may be offered daily heparin injections and compression stockings for 10 days; your midwife can teach you and your partner to give them.

You and your partner may find it helpful to talk through events. The RCOG says you will have the opportunity to discuss what happened before you leave hospital, may request a further meeting with a senior team member, and should talk to your midwife, health visitor or GP if you develop anxiety or depression. It lists the Birth Trauma Association and the Maternal Mental Health Alliance as support.

After a primary PPH the risk in future births is increased, which is why the RCOG says you will be advised to give birth in a consultant-led unit, may be advised iron supplements in pregnancy, may have blood tests and a drip in labour, and will be offered medicine to help the placenta come away.

The NHS says to call 999 if postnatal bleeding is sudden and very heavy or you feel faint, dizzy or have a pounding heart, and to speak to your GP, midwife or health visitor if bleeding gets heavier, does not lessen, smells unusual, contains lumps, or comes with a temperature over 38C or worsening tummy or perineal pain. Arrangements for home and unit births differ across the UK.