Postpartum hemorrhage is rare in physiological birth, but it remains a concern for many planning a home birth. This free three-part guide unpacks what postpartum hemorrhage actually is (hint: it’s not just about how many ounces of blood you may lose) and how to help prevent and reduce it in a truly holistic way. It goes over nutrition, herbal support, homeopathics, birth physiology, and birth environment—so, dive in!
Contents
Postpartum Hemorrhage: Three-part Series
- Part 1: Postpartum Hemorrhage: a Holistic Take on Causes & Risks
Be sure to check out the whole series!
Postpartum Hemorrhage from a Holistic Perspective
Postpartum hemorrhage vs. bleeding
Postpartum hemorrhage is not just about measuring how many milliliters of blood you lose, it’s about how you feel and whether your body is working to regulate the bleeding.
The conventional medical obstetric model defines postpartum hemorrhage as blood loss greater than 500 mL in the first 24 hours after birth (Akins, 1994).
This mechanistic medical definition has many flaws. It doesn’t take into account how the woman feels, what’s normal for her physiology, and whether there are any other factors that might make the situation riskier (e.g. surgical birth vs. vaginal, medical interventions used, general health status, etc.). It doesn’t even take into account whether the blood loss is happening from the uterus or from the perineum due to tearing or episiotomy.
Science is beginning to catch up with physiology and many researchers have outlined the problem with defining postpartum hemorrhage just as the amount of blood loss.
Research shows that normal blood loss in a vaginal delivery may exceed 500 mL and can range from 500-1000 mL. According to some, 1000 mL would be a more realistic expectation for vaginal birth anyway (Akins, 1994).
The American College of Obstetricians and Gynecologists states there is “no universally accepted definition” of postpartum hemorrhage (Akins, 1994).
Beyond any blood loss measurement, hemorrhage implies uncontrolled bleeding that triggers symptoms. These may include lightheadedness, uneasiness, weakness, trembling, and others that warn the body that something is not right.
One woman may lose over a liter of blood but feel fine and her body may efficiently stop the bleeding afterward. This would be defined as hemorrhage in a medical but not in a holistic, physiological sense. Another woman may seriously struggle with losing 450 mL (this is unlikely, but possible). The whole scenario is affected by bodily processes, environment, and psychological factors (fear, anxiety, preconceptions, etc.).
What Causes Postpartum Hemorrhage?
Technically speaking, postpartum hemorrhage happens either when the uterus is not contracting enough after birth or when pieces of the placenta remain attached.
After a baby is birthed, the uterus normally continues to contract. Uterine muscles get tighter and tighter, and the placenta detaches. Once detached, it can be easily birthed. In most cases, it just slides out and the woman feels a mild contraction (mild compared to contractions that help birth the baby, anyway).
After birthing the placenta, the uterus continues to contract. This helps compress the bleeding vessels in the area where the placenta was attached. So, if the uterus doesn’t contract strongly enough (termed uterine atony), these blood vessels bleed freely. If they continue to stay open, hemorrhage occurs. This is the most common cause of postpartum hemorrhage.
There are two main reasons the uterus might not be contracting as it should: hormonal imbalances or something mechanically getting in its way (most often a full bladder).
Oxytocin—the “love and labor hormone”—makes the uterus contract. The uterus will stay relaxed if there is not enough oxytocin or if it can’t mount a response to oxytocin. The latter often happens when the oxytocin receptors of the uterus become oversaturated from large doses of synthetic oxytocin over a long time (Belghiti et al. 2011; Phaneuf et al. 2000).
The second most common cause is if pieces of the placenta remain attached. In this case, bleeding is likely. But, we don’t have enough data about how often it happens in physiological, undisturbed birth and whether small pieces that might remain attached without causing symptoms are a problem if no medical interventions were used.
We do know that medical interventions like Pitocin and manually forcing the birth of the placenta increase the chance of pieces remaining (Meyer et al., 2020; Anteby et al., 2019)
Other possible and extremely rare causes include perineal/cervical damage and clotting disorders.
Summary:
To sum it up, your uterus needs to effectively contract to prevent excessive bleeding after birth. Oxytocin is one of the key birthing and bonding hormones, and it works best when birth is left to unfold physiologically. Synthetic oxytocin increases the risk of hemorrhage.
Postpartum Hemorrhage Risk Factors During Pregnancy
These pregnancy risk factors are mentioned in the literature that analyzed hospital births only (Fukami et al., 2019; ):
- Age < 18 years
- Previous cesarean section
- History of postpartum hemorrhage (PPH)
- Conception through IVF
- Pre-delivery anemia
- Hypertension
- Vaginal or perineal lacerations
Please take them with a grain of salt, as it’s uncertain how much each individual one can affect the overall risk. Don’t let them scare you. For example, you may be 17 or you may be 40 and have conceived through IVF and go on to have a completely beautiful and normal physiological birth.
These risk factors start to make sense only when they’re looked at holistically, along with everything else that affects birth and bleeding afterward.
Also, the studies mentioning these risk factors have no data on home births and physiological birth. Some even suggested race as a risk factor (Asian or Hispanic ethnic background) while failing to take into account the impact of systemic racism, obstetric abuse, and various cultural factors on birth outcomes (Harvey et al., 2017).
Postpartum Hemorrhage Risk Factors During Birth
The following interventions during birth increase the risk of hemorrhage (Belghiti et al. 2011; Phaneuf et al. 2000; Anderson & Etches, 2007; Hassan et al., 2021; Petrocnik & Marshall, 2015):
- Pitocin induction/augmentation
- Coached pushing
- “Hands-on” birth (anyone touching your perineum during birth)
- Routine episiotomy
- Forceps or vacuum-assisted delivery
- General anesthesia
- Routine Pitocin after birth (active third stage management) in cases of natural, physiological birth
Let’s break down that last point…
In obstetrics, giving Pitocin to everyone “just in case” is termed active third stage management. (The term itself is misleading whereas we should really be saying “medicalized placental birth”)
There’s a wide misconception that this approach reduces postpartum hemorrhage in all cases. However, research shows that while it does have this effect in cases of medicalized birth, it does the opposite in physiological birth! (Fahy, et al. 2010)
Yet, far too few studies actually include women experiencing physiological births. One study found that active (aka medicalized) management was linked with a 7- to 8-fold increase in postpartum hemorrhage rates compared to a holistic physiological approach. Importantly, the midwives attending physiological placental births were familiar and comfortable with this approach (Fahy, et al. 2010).
According to another retrospective study, active management increased large postpartum hemorrhage (losing over 1000ml) two-fold in low-risk women, compared to physiological placental birth (Davis et al. 2012).
Yet another 2018 study found the same: in women having more physiological, natural births, active management was associated with a higher risk for PPH and placental delivery >30 minutes. They concluded that active third stage management may not be as beneficial to women undergoing physiologic birth (Erickson et al., 2018).
To sum it up, if you’re having an undisturbed physiological birth, routinely receiving Pitocin for placental birth increases your risk of postpartum hemorrhage. Check out Rachel Reed’s article which fantastically analyzes these studies in much more detail.
Find out about the risks of Pitocin your doctor is unlikely to mention in my post here.
Other factors mentioned in the literature that may increase the risk of postpartum hemorrhage in hospital births only include: stillbirth, placenta previa, placental abruption, placenta accreta spectrum (placenta that grows too deep into the uterus), macrosomia (“big baby” – something I personally don’t believe with as it doesn’t take into account the whole range of physiologically normal), and prolonged labor (very relative, especially in physiologic settings). (Liu et al., 2021).
We don’t know if these factors also affect hemorrhage in undisturbed, home birth, and many of these factors are highly debatable diagnoses anyways.
The main takeaway is that it’s not about measuring milliliters of blood loss but attuning to your body in a supportive and intimate birth environment that supports physiology.
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The founder of Herbal Doula.
Home-birthing mama, independent scientist, natural pharmacist, doula, birthkeeper, and holistic health and birthrights advocate. Endlessly passionate about creating and sharing empowering health information and birth support. Ana has written 150+ and edited 800+ articles, some of which reached over 1 million people
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