Understanding Postpartum Hemorrhage and Delayed Warning Signs

By Birth & Baby University · Last updated: October 2026 · 4 min read

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide, and it is not only an event in the delivery room. Bleeding can build gradually, hide inside the abdomen after cesarean, or return days or weeks after birth. Doulas do not measure or treat blood loss, but they can know the warning signs and help families act fast.

Key takeaways

• ACOG defines hemorrhage as cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of low blood volume, within 24 hours of birth, and calls it the leading cause of maternal mortality worldwide.
• A systematic review found that visual estimation of blood loss misses about half of cases at vaginal birth (pooled sensitivity 48 percent).
• In the E-MOTIVE trial, early objective detection and a treatment bundle cut the composite of severe hemorrhage, laparotomy for bleeding or death from bleeding from 4.3 to 1.6 percent.
• After discharge, heavier or persistent bleeding, large clots, foul smell, fever, faintness, dizziness or a pounding heart need immediate contact with a clinician or emergency services.

What the research says

Definition and scale

ACOG Practice Bulletin 183 defines maternal hemorrhage as cumulative blood loss of 1,000 mL or more, or blood loss with signs of hypovolemia, within 24 hours after birth, and describes it as the leading cause of maternal mortality worldwide and the leading cause of severe maternal morbidity in the United States when it leads to transfusion. It also notes that the U.S. rate increased 26 percent between 1994 and 2006, mostly because of uterine atony. A 2026 Lancet review estimates that PPH affects about 13 percent of women with vaginal birth and 31 percent with cesarean birth, using measurement-based definitions, which is why detection methods matter.

Detecting it early

The same review reports that a systematic review found subjective visual estimation misses 52 percent of PPH diagnoses at vaginal birth (pooled sensitivity 48 percent, 95% CI 44 to 53), and probably more at cesarean, and that consolidated WHO, FIGO and ICM guidelines recommend objective quantification with tools such as a calibrated blood collection drape. The E-MOTIVE cluster-randomized trial across 80 hospitals in Kenya, Nigeria, South Africa and Tanzania (210,132 vaginal births) tested a drape plus a first-response treatment bundle. The primary outcome occurred in 1.6 percent with the intervention and 4.3 percent with usual care (RR 0.40, 95% CI 0.32 to 0.50), with PPH detection in 93.1 versus 51.1 percent. The trial was in secondary-level hospitals in four African countries, so settings differ from many U.S. units.

Delayed and hidden bleeding

A 2026 review of immediate and delayed hemorrhage with cesarean birth advises that delayed hemorrhage should be considered a likely cause of any change in a mother’s clinical condition in the hours after cesarean, even without vaginal bleeding, because bleeding can occur into the abdomen or behind the peritoneum and may not appear as vaginal bleeding. A review of puerperal complications lists bleeding and disturbances of uterine involution among the most common and severe early complications. At home, UK hospital guidance (a patient factsheet) advises contacting a midwife or GP straight away for large clots after the first 24 hours, bleeding heavier than before or still heavy beyond a week, or offensive smell, and the NHS says to call 999 for sudden, very heavy bleeding or faintness, dizziness or a pounding heart. Thresholds for pads and clots differ between organizations.

Warning signs

The CDC’s urgent maternal warning signs include dizziness or fainting, chest pain or fast heartbeat, trouble breathing, fever, severe belly pain and vaginal bleeding or discharge after pregnancy, and apply for up to a year after delivery.

What this means for doulas

• Do not estimate blood loss. Appearance misleads even clinicians. If you are at a birth, tell the nurse or midwife what you see and ask if they are measuring.
• Know the signs of heavy blood loss. Pallor, dizziness, weakness, racing heart, sweating, anxiety or restlessness, and sudden change in condition require immediate help.
• Teach clients before they leave. Give clear instructions on pad counts, clots, smell, fever and when to call 911 or the care team, according to local advice.
• Ask follow-up questions. If a client mentions heavier bleeding, ask how many pads, how big the clots are and how she feels, then encourage a call to the provider.

Putting the evidence into practice

• Add a bleeding section to your postpartum handout with the local care team’s numbers and thresholds.
• At every postpartum visit, ask about bleeding and fatigue, and look for pallor or breathlessness.
• Keep emergency numbers and a plan for transport to the hospital with clients’ partners.
• After a hemorrhage, offer practical and emotional support. Recovery can involve iron treatment, fatigue and fear, and clinicians guide medical follow-up.

The bottom line

Postpartum hemorrhage is common enough, dangerous and easy to under-recognize. The best defense is early objective detection by clinicians and, at home, families who know the warning signs and are told to call at once. Doulas serve by teaching, noticing and escalating.

This article is for professional education. It is not medical, legal or tax advice. Check the standards of your certifying organization and the rules where you work.

Sources and further reading

• American College of Obstetricians and Gynecologists. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology 2017. Read the source
• Coomarasamy A, et al. Diagnosis and treatment of postpartum haemorrhage: a race against time. Lancet 2026. Read the source
• Gallos I, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage. New England Journal of Medicine 2023. Read the source
• Madar H, et al. Management of immediate and delayed postpartum hemorrhage with cesarean delivery. American Journal of Obstetrics and Gynecology 2026. Read the source
• Schrey-Petersen S, et al. Diseases and complications of the puerperium. Deutsches Arzteblatt International 2021. Read the source
• University Hospitals Southampton NHS Foundation Trust. Blood loss: what to expect after the birth of your baby. Patient information factsheet, read 16 October 2026. Read the source
• Centers for Disease Control and Prevention. Urgent Maternal Warning Signs, Hear Her campaign. Web page, read 16 October 2026. Read the source

Recognizing and escalating warning signs quickly is a core professional skill. See the birth and postpartum doula training and mentorship options on the For Doulas page.

More for professionals: the Professionals Blog.