Gorovitz & Borten, P.C.
Attorneys at Law

550 Cochituate Road, Suite 25
Framingham, Massachusetts
Tel: (781) 890-9095
Postpartum Hemorrhage
While the delivery of a healthy infant is an essential goal of obstetrics and the
immediate postpartum period is usually uneventful, significant and serious
complications can occur. Management of the third stage of labor (between the
delivery of the baby and the delivery of the placenta) and  the subsequent few
hours require close attention by the medical providers. The most serious
complication following delivery of the baby remains postpartum hemorrhage
which is a significant cause of maternal morbidity and mortality.  

Postpartum hemorrhage is the acute loss of more than 500 cc. of blood that
occurs following the delivery of the baby. It complicates approximately 2% to 10%
of all deliveries but is severe in only 1% of cases. Postpartum hemorrhage is
associated with increased maternal morbidity and mortality. Factors that increase
the risk for a postpartum hemorrhage to occur include:

Uterine contraction following the delivery of a baby is responsible for controlling
blood loss. Clot formation also plays an important role in limiting the amount of
blood lost following delivery and the subsequent days. Changes occurring during
the course of a pregnancy helps protect against the complications of postpartum
hemorrhage. Maternal blood volume normally increases approximately 50% and
protects the mother against postpartum hypotension and anemia. A marked
increase in clotting factors and decrease in fibrinolytic activity help in the clot
formation and fibrin deposition following delivery of the placenta.

Uterine atony, a condition in which the uterus fails to contract following the
delivery of the placenta, accounts for most cases of postpartum hemorrhage.
Abnormal labor, an overdistended uterus, the use of Pitocin and the presence of
a uterine infection (chorioamnionitis) appear to predispose to uterine atony.
Severe postpartum uterine bleeding as a result of failure of the uterus to contract
(atony) accounts for more than one third (33%) of postpartum hysterectomies.

Several agents cause the uterus to contract following delivery of the placenta.
Oxytocin (Pitocin) that is naturally produced in the posterior pituitary can also be
administered intravenously. Prostaglandins, locally produced by the uterus can
also be administered by various routes to produce the uterus to contract. Other
medications have the opposite effect, mainly uterine relaxation which can lead to
dangerous bleeding following delivery. Drugs used around the time of delivery
that are associated with uterine relaxation include:

  • Beta-sympathomimetics (terbutaline, ritodrine)
  • Nonsteroidal anti-inflammatory (ibuprofen)
  • Calcium antagonists (Nifedipine)
  • Magnesium sulfate
  • Anesthesia gases (Inhalation agents)

Controversy still exists concerning the benefit of active management compared
with the expectant management of the third stage of labor. Several studies have
shown that active management of labor is associated with a decreased
occurrence of postpartum hemorrhage. Retained placenta or a portion of the
placenta is a common cause of postpartum hemorrhage. Retained placenta is
more common following delivery of very premature infants. Complications such
as placenta accreta (absence of normal cleavage plane between the placenta
and the uterus) or placenta increta when the placenta has grown into the uterine
muscle, require at times surgical intervention.

Treatment of a postpartum hemorrhage sequentially consists of medical,
interventional and ultimately surgical options.

Medical Treatment
  • Uterine massage
  • Oxytocin (Pitocin) infusion
  • Ergot derivatives (ergonovine, ergometrine)
  • Prostaglandin F2α (carboprost tromethamine)

Interventional Treatment
  • Selective angiography
  • Vasopressin infusion

Surgical Treatment
  • Uterine curettage (D & C)
  • Utero-ovarian artery ligation
  • Uterine artery ligation (O’Leary method)
  • B-Lynch stitch(es)
  • Hypogastric artery ligation
  • Hysterectomy

Not all postpartum vaginal bleeding originates from the uterus. Injuries to the
birth canal such as vaginal and cervical lacerations are a common source of
postpartum hemorrhage.
Forceps delivery following a prolonged labor and/or
performed under emergency circumstances is a frequent cause of lacerations of
the birth canal. Failure of the postpartum hemorrhage to respond to uterine
massage and/or the administration of uterotonic agents should raise the
suspicion that injury to the birth canal is the source of the blood loss.

When the drastic decision to perform an hysterectomy is taken, preservation of
the ovaries is essential. Women who have just delivered an infant are generally
young and surgical menopause resulting from removal of their ovaries exposes
them to the risk of subsequent long term complications. Knowledge of the pelvic
anatomy and the experience to deal with a serious complication such as
postpartum hemorrhage that requires a surgical intervention are extremely
important. Attempts by inexperienced surgeons to surgically treat severe
postpartum hemorrhage have been associated with undesirable surgical

Treatment of severe postpartum hemorrhage (with or without shock) requires
massive replacement of blood and crystalloid solutions. Electrolyte imbalance
(hypokalemia, hypocalcemia) as well as hemodynamic changes require close
monitoring and frequent interventions. Successful treatment of severe
postpartum hemorrhage requires a multidisciplinary approach with close
collaboration among members of the care team (obstetrician, nurses,
anesthesiologist and consultants).

Medical providers are responsible for the diagnosis and management of
complications that arise during the third stage of labor such as postpartum
hemorrhage. If you believe that you, your child or your loved one have been
misdiagnosed, are victims of a postpartum hemorrhage or wrongly treated and
suspect the postpartum complications may be the result of a  medical provider’s
error that was diagnosable, avoidable and/or preventable, you may have a valid
cause of action. The injury may be the result of a medical provider's mistake in
handling your condition and the result of medical negligence.
Dr. Borten has
over 35 years of experience as an obstetrician and gynecologic surgeon to fully
evaluate the merits of your potential case. Allow the Boston area medical
malpractice attorneys at Gorovitz & Borten help you assert your rights and get
the compensation you deserve.
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Questions or Inquiries to: inquiry@gbmedlaw.com

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