Synopsis
Assess delayed abnormal bleeding after birth, distinguish recovery from infection or retained tissue, and organise resuscitation, specialist treatment and recovery follow-up.
- Secondary postpartum haemorrhage occurs after twenty-four hours and up to twelve weeks.
- Assess the woman's circulation and the bleeding trajectory together.
- Endometritis and retained placental tissue are important treatable causes.
- A scan showing intrauterine material does not prove retained products.
- Senior supervision is essential when postpartum uterine evacuation is required.
- Plan anaemia treatment and emotional recovery after bleeding settles.
Key red flags
Ongoing brisk bleeding with dizziness, collapse or reduced responsiveness.
Recurrent large clots accompanied by increasing abdominal pain.
Offensive lochia, rigors or fever with worsening bleeding.
Recurrent substantial bleeding despite an earlier apparently reassuring assessment.
Investigation priorities
Estimate anaemia and guide subsequent recovery planning.
Management branches
Bleeding is brisk or the woman shows physiological compromise.
- Summon the obstetric haemorrhage team and anaesthetist, obtain large-bore intravenous access and send urgent blood tests.
- Begin monitored resuscitation and blood component support according to the major haemorrhage pathway while quantifying continued loss.
- Assess uterine tone, infection and trauma concurrently, with early consultant decisions about theatre or interventional radiology.
The woman remains stable but bleeding is abnormal or recurrent.
- Perform a focused history and examination, review the birth record and arrange blood count and appropriate imaging.
- Treat suspected infection using the obstetric antimicrobial pathway, deciding whether oral treatment or hospital intravenous therapy is appropriate.
- Discuss expectant management or uterine evacuation with a senior clinician according to bleeding, findings and the woman's preferences.
Key medicines
Ergometrine for selected uterine bleedingFor specialist treatment of postpartum uterine atony, 500 micrograms intramuscularly is a standard dose; severe atonic haemorrhage may require 250–500 micrograms by slow intravenous injection with monitoring.The cited SmPC contraindicates severe hypertension, pre-eclampsia, eclampsia, severe cardiac disease, severe hepatic or renal impairment, occlusive vascular disease and sepsis. Use caution with milder hypertension or organ disease. Repeated administration can suppress lactation; persistent bleeding needs reassessment for retained tissue, trauma or coagulopathy before another dose.
Antibiotics when endometritis contributesOne NHS Lothian postpartum regimen is co-amoxiclav 1.2 g intravenously every 8 hours, with 625 mg orally every 8 hours after suitable improvement, completing 7 days in total.Check penicillin allergy, kidney function and previous hepatic reaction. Major bleeding, systemic infection or suspected retained infected tissue requires hospital assessment and possible source control rather than an oral prescription alone.