Which complication is most likely responsible for delayed postpartum hemorrhage?

• A. Uterine subinvolution
• B. Cervical laceration
• C. Clotting deficiency
• D. Perineal laceration

Answer: (A)

Delayed postpartum hemorrhage is best explained by subinvolution of the uterus—the uterus fails to return to its nonpregnant size after birth. This condition often arises when placental tissue remains in the uterus or when infection disrupts healing of the placental site. Because the uterus doesn’t involute properly, bleeding persists or recurs and lochia remains heavier than expected, with a fundal height that stays larger than normal for the time after birth.

Understanding this helps: the issue is not a tear or laceration of the cervix or perineum, which would cause bleeding soon after delivery, nor is it typically due to a coagulation problem that would present as widespread or ongoing bleeding from multiple sites from the start. The key indicator of subinvolution is prolonged, recurrent vaginal bleeding associated with a uterus that stays enlarged or boggy as it should be contracting down. Management focuses on confirming retained products or infection, treating infection, and using measures to promote uterine involution, such as appropriate antibiotics if infection is present and, if needed, removal of retained tissue.