Excessive Bleeding After Birth and Thoughts on Prevention
In a normal birth after your baby comes out, there is bleeding from your womb where the placenta has detached. This is normal and expected! It may look like a lot, especially if you have never seen it before, but this is a physiological part of the birth process. There is a "placenta-size wound" now in your womb. Your uterus will contract and stop blood flow to the site over the course of the next few minutes, hours, and days.
Too much bleeding immediately after birth (a.k.a. postpartum hemorrhage) can sometimes be a concern and even in some cases a real emergency. While a true postpartum hemorrhage is one of the bigger complications that can happen in a birth, it's important to note that hemorrhage can be a subjective term as the amount of blood is visually estimated by the provider. There are also differing guidelines and thresholds for what that means depending on place and provider. What one provider means by hemorrhage is not the same as another. Some hemorrhages might be really obvious while many might be debatable or the result of an inexperienced or nervous provider. Also worth knowing is that different women will have different thresholds of blood loss! What might be concerning for one woman might not be for another.
While it does account for a significant amount of worry by providers and is one of the top causes of emergency, it is empowering to learn that there are things we can do to help prevent it from happening and there are also ways during pregnancy to increase our body's ability to withstand blood loss that does occur! Not only that but there are a variety of ways it can be managed if it does start to happen.
Here are a few thoughts to consider:
Drink a quart of NORA tea daily (nettle, oatstraw, raspberry leaf, and alfalfa) the last 6 weeks of pregnancy. The ingredients will build up vitamin K (necessary for clotting) and iron stores and help tone the uterine muscles. Find the recipe here!
Ensure you are getting enough calcium and iron while pregnant. While best sourced from your diet, many women find they need a quality supplement as well, especially for iron. Consider using one that is food-based rather than synthetic. Desiccated liver is actually a wonderful source and doesn't have the same side effects (like awful constipation!) that synthetic iron can cause.
Empty your bladder often during labor. A full bladder can not only impede the descent of the baby but also can limit how well the uterus can contract afterwards. A good rule of thumb is to use the bathroom every 1-2 hours in labor. A good doula will remind you of this but it's also a good thing for a husband to be cognizant of and remind you of if needed.
Stay upright and mobile during labor to facilitate a quicker labor. A very prolonged labor, while not an issue in itself, is associated with more postpartum bleeding. Staying upright, following your physiological instincts with positions, and helping your body to work as it is designed is important.
Choose a provider who understands the physiology of the third stage of labor and will not rush or pull on your placenta. Some providers in their rush or worry will actually pull on the placenta before it has completely detached itself from the wall of the uterus. This is incredibly dangerous and can cause a postpartum hemorrhage or even a uterine prolapse. Once it is clear the placenta has detached, a bit of light traction to help it come out is not harmful (but still should be with your consent if done by someone else). Having the placenta out can also make it clearer how much a mother is bleeding since a detached placenta sitting right in the cervix or in the vagina can make it hard to assess.
Make sure the placenta is checked thoroughly to ensure it is whole and everything is out including membranes. A bit of placenta or amniotic sac left in the womb can cause a mother to bleed more or introduce an infection.
Avoid Pitocin use during labor. This is a big one. Our bodies do not respond the same to artificial Pitocin as they do to our natural oxytocin. Pitocin and oxytocin are NOT the same thing. Because it is not self-regulated, Pitocin can overwhelm the oxytocin receptors within the uterus and essentially overtax it. If that happens, the uterus may not be able to contract efficiently after birth as it naturally would and control the bleeding.
Keep baby with you skin to skin immediately after birth and at least the first few hours after. Our body responds to holding and smelling our baby by releasing more oxytocin. This oxytocin release helps the uterus to contract and shrink back down and slows or stops bleeding. Holding and nursing our babies literally helps us heal and recover. God's design is incredible.
On that note, keep baby’s head uncovered to facilitate that olfactory induced oxytocin release! There's a tendency in many birth settings to immediately put a hat on the baby to "keep them warm". In normal circumstances your body is enough to keep them warm and the idea that we lose most of our heat through our heads is actually a myth. If temperature is a concern we can cover mom and baby together with blankets but keep them skin to skin and baby's head uncovered. Keep in mind the human race survived for millennia without someone immediately putting a hat on baby's head (or a lot of other things we think we need to do, for that matter).
Breastfeed as soon as baby is ready. Breastfeeding releases huge amounts of oxytocin. You may even find that it triggers very intense contractions, especially if you've had babies before.
Keep the immediate postpartum environment similar to an optimal labor environment - soothing, low lights, encouraging words, warmth, etc. Think of things that keep oxytocin flowing. Unnecessary panic, bright lights, strangers, and cold are all enemies of oxytocin.
Learn how to feel the top of your uterus (fundus) after birth. It should feel firm and gradually getting smaller to just at or below your belly button. If it doesn't, you can rub it to stimulate contractions. This fundal "massage” is frequently and routinely done in hospital settings by nurses and often is extremely uncomfortable. However, if there is no indication of a problem, it is not necessary or evidence based.
Know the different medications and herbs available to you to address excessive bleeding if it does occur. Different settings will have different options. The most commonly used medication is Pitocin, synthetic oxytocin, either via IV or through an intramuscular shot in the thigh. Cytotec is another one that is frequently used either as an oral pill to dissolve in your cheek or inserted rectally. Tranexamic Acid (TXA) and methargine are other medications used in some settings. Shepherd's purse is an herb used in tincture form that can help slow bleeding. Some mothers will even use a small piece of placenta or membrane and place it inside their cheek which can be very helpful for bleeding! This is not an exhaustive list but simply some of the most common methods for intervening. You can talk with your provider about what their approach is if this becomes an issue.
For a mom with greater risk factors for bleeding, "active management of the third stage" is often recommended. This means automatic Pitocin given immediately after birth regardless of current estimated blood loss seen in order to possibly prevent a hemorrhage. You can find more information on that approach HERE. Be aware that in almost every hospital setting, automatic Pitocin is the norm regardless of risk factors or bleeding for every single mother and is often done without mom even being aware. If this is not something you want, you will have to be proactive about making sure it is not given.
While a true hemorrhage is something that should be taken seriously, it's important and beautiful to remember that God knew what He was doing when He designed our bodies. Hemorrhage should not be common and if it is, we should examine why it is happening. He designed our bodies to birth our babies and to recover from that process. The more we support that design, nourish our bodies well, and learn when intervening is merited, the better and healthier our births become.