Your baby was just born! But wait…there’s more: third stage of labor and postpartum bleeding
Let’s talk a little about what happens after your baby is born. Usually, if birthing vaginally, there is a short delay between the time your baby comes out and the actual end of the birth—you’re not done just yet! This is the third stage of labor—the time between the birth of the newborn baby and when the placenta is born. During this stage, your new baby may be in your arms, possibly even latched on, but the birth is not yet over. This is a time for calm, connection and care.
What is normal third stage labor?
During pregnancy, the placenta makes a very firm attachment within the wall of the uterus, which is necessary to get the placenta’s tissue close enough to the maternal blood supply and allow ALL of the good (and sometimes not so good) things in the person’s blood to move across the membrane of the placenta into the fetal blood. The fetus also gets rid of wastes through the placenta, which then the pregnant person can remove though their body. The pregnant person provides nutrients like glucose (sugar), fats, proteins as well as oxygen to the fetus. So the connection between the placenta and the uterus is really critical for successful pregnancy.
After birth, the uterus is smaller because a baby just came out, the walls of the uterus fall inward and down, clamping down on the uterine blood vessels that were nourishing the placenta. This causes the placenta to peel or release from the site where it had attached. But—if the blood vessels don’t stay clamped tight, the “wound,” or attachment site where the placenta had burrowed in, will continue to bleed.
Most midwives prefer to wait to clamp the cord until the cord stops pulsing or looks slack and pale, as the blood has finished getting back to the baby that was stored in the placenta during labor. If your provider recommends early cord-clamping, this is usually because the baby needs help breathing, sometimes this means moving the baby to a flat surface (like a nursery warming bed) and using oxygen. Midwives who practice in the community setting (home births) sometimes can provide this kind of care with the cord attached, but it is not always possible.
However, one benefit of getting as much blood as possible into the baby from the placenta, is that it helps shrink the placenta slightly.
Typically the wait for the placenta can take anywhere from a few minutes to up to 30 minutes. Some midwives and physicians are comfortable waiting up to 1 hour for the placenta to emerge, but others may recommend helping it come out after 30 minutes. You may experience cramping, though usually not as severe as labor contractions. Sometimes when the placenta is ready to be born there may be a small gush of blood.
Some things that can help get the uterus to contract/clamp down faster include:
- Skin-to-skin with baby right after birth is one of the best ways to keep the birthing mother calm and enjoy those first precious minutes of life with you new baby, it also helps release oxytocin, which helps your uterus contract.
- Placing your baby on the breast, in attempts to latch and begin breastfeeding also helps make more oxytocin!
- Emptying the bladder by urinating or using a small catheter to drain the urine
- Using medications like oxytocin (Pitocin®) given through an IV or as an injection into your thigh
We know through research that oftentimes the longer it takes for the placenta to come out, the more likely it is that a person will have too much bleeding or a postpartum hemorrhage.
How much is too much bleeding postpartum?
This is a good question and one that probably is based on YOU as an individual more than what the textbooks say. In fact, the definition of postpartum hemorrhage (PPH) has changed in recent years because of new understanding around who is really at risk for problems related to bleeding.
Before we get into that, it is important to remember that your body has been preparing for birth and the possibility of bleeding for many months. The pregnant body actually makes an additional 1.25 liters of blood (about 5.25 cups) during pregnancy. Probably some people will make slightly more / less depending on their body size.
This is spare blood, and otherwise healthy women can probably do pretty well after birth if they lose up to 1 liter (1000mL) of blood. So the definition of PPH –or too much bleeding—is 1 liter or more in the first 24 hours after birth. However, it is tricky because sometime people do not make this much blood, or have other health issues like anemia during pregnancy and they might feel more side effects of PPH if they lose only 500mL or 750mL. The point is that we have to consider you as a person when thinking about what is “abnormal vs. normal”.
So why do some people have more PPH than others—here are some common reasons or “risk factors” for PPH as well as the reason behind them.
Causes for PPH
Uterine Fatigue (called atony)
- A long labor, long pushing stage (more common after a first-time birth)
- Bigger baby = bigger size placenta
- Bigger uterus (for example multiple gestation or lots of amniotic fluid)
- Having treatment for preeclampsia during labor called Magnesium Sulfate
- Use of oxytocin to stimulate labor contractions or to induce labor
- Infection during labor
Tears (lacerations) in the vaginal or perineal area OR Cesarean Birth
- These lacerations can bleed a lot sometimes if they are deep into the muscle (more common with first-time births and when vacuum or forceps is used for birth)
- Cesarean involves cutting directly into the uterine muscle, which tends to bleed a lot when cut, especially if you are already in labor when the Cesarean was needed.
Blood clots, pieces of placenta or bag of water (membranes) stuck inside
- These little pieces (or sometimes big pieces) are often the cause of bleeding right after birth because they keep the uterus from clamping down
Conditions that keep your body from clotting your blood properly
- Conditions like von Willebrand’s disease or having low-platelets contribute to some cases
Abnormally grown placentas
- These conditions are called placenta accreta (increta/percreta) and all of these involve the placenta actually burrowing down deeper into the uterus than normal, which makes it very difficult to remove without surgical intervention. Often this is associated with having a prior uterine surgery (cesarean) or with some pregnancies that used IVF for conception.
Can PPH be prevented?
Prevention of PPH involves consideration of everything about your health from pre-pregnancy, to pregnancy , birth and postpartum. Here are some things to consider:
Improve or maintain healthy nutrition during pregnancy, especially preventing or treating anemia. Researchers have shown that low iron (anemia) can be a risk for PPH as well as needing a blood transfusion. Ask if your midwife/doctor has checked your blood in the third trimester for anemia. Sometimes a ferritin test may be added—this tells us about the amount of iron you have stored in your body.
In addition, a blood sample can show if you have low platelets, if you do, your blood might have a harder time clotting properly, and there is treatment for this.
Consider having labor support people who will be focused on helping you stay calm in labor, some people use a doula –a professional labor supporter (often they are volunteers). People who have continuous labor support don not appear to need as much intervention during the birth process, like Cesarean, epidurals and or possibly the need for oxytocin to speed up labor.
Request that vaginal/cervical exams are only performed when absolutely necessary to avoid more risk of infection during labor that can increase PPH risks.
Talk to your provider about all of your options if they recommend labor be sped up with oxytocin, sometimes this is needed because your labor is going very slowly but sometimes a little more time and patience will work too.
Oxytocin can be given right after birth to help prevent uterine atony (fatigue), which is responsible for most PPH. This medication can be given as an injection or through the IV. Many, but not all, studies show that this helps reduce the rate of PPH. It is probably most helpful for PPH prevention if your labor has been prolonged, needed oxytocin to help it along, or if you are a first time parent.
If you are at high risk for PPH (see chart below), then you might opt for oxytocin after birth rather than waiting to see if you have heavy bleeding that will need to be treated with medication.
Talk to your provider about ways to help limit tearing in the vagina during pushing, avoiding routine episiotomy may be one option. You may consider trying pushing in a hands and knees position, side lying or more upright to help avoid the need for vacuum or forceps.
Severe Postpartum Hemorrhage:
Severe PPH rates are increasing in the United States. In the US, most births occur in the hospital and usually medical staff can quickly control and treat the bleeding, so deaths from PPH are not very common in the US (about 11% (77) of the annual 700 maternal deaths each year). More interventions are being done to help control PPH in the US over the last 25 years, which means that probably women are bleeding more—but we are also doing a good job treating it. However, for some people PPH treatment involves blood transfusion, additional procedures to remove trapped placental tissue or in the more severe cases, a surgery to remove the uterus (hysterectomy).
Delayed Postpartum Hemorrhage:
After going home from the hospital or several days after birth, some people experience a late or delayed PPH. It is important to know when to call your provider to report that you have heavy bleeding because it may mean you still have some pieces of placenta inside or that you have an infection.
Call your provider if you have:
- soaked through 1 thick/full sized pad in one hour for 2 hours in a row or are passing large clots (egg sized)
- a fever >100.4 degrees
- tenderness / pain over your uterus, more than in prior days
- note a bad-smelling odor from the vagina or abnormal discharge
- feel lightheaded, dizzy, headaches, excess fatigue (as you may have anemia)
Do you have risk factors for PPH?
AWHONN Postpartum Hemorrhage Risk Assessment Table provides a detailed breakdown of low, medium and high risk factors for you to consider.
Postpartum hemorrhage for people of color
Data from research studies show us that people of color, in particular Black and Latinx people, may experience more PPH or may have more severe health effects from PPH (like needing more transfusions or hysterectomies or even death).
Some reasons for why this happens may be inequitable access to effective prenatal care or nutritious iron-rich foods before and during pregnancy. If prenatal treatment for anemia was not adequate, experiencing heavy bleeding after birth may make a person more likely to need a transfusion. In addition, issues like hypertension or stressors that complicate general health may be involved. One study of about 25,000 vaginal births (that I was involved in) found that when labor was complicated, PPH was more common; however, even when labor was not as complex, people identified as Black or Hispanic were more likely to have PPH compared to those who were white.
We do not know that PPH-related complications happen disproportionately more often for people of color because of birth events themselves or from things like pregnancy related anemia. However, there is growing awareness that oftentimes people’s general concerns/complaints about their health are not responded to adequately sometimes —leading to delays in their care. This needs to change.
If you are concerned about PPH in particular, if you or a close family member have had a PPH in a past birth or have any of the medium/high risk factors listed above—bring up your concerns during a prenatal visit or at the start of your labor admission. Also, listen to your inner voice and if you think something is wrong, keep asking for help until you get the attention you deserve. One of the midwives’ mottos is “listen to women” but that does not mean that we do not make mistakes in making sure everyone is “heard,” and we appreciate feedback to help us improve.
Treatment During a Postpartum Hemorrhage
Finally, in this section we talk about what having a PPH is like, and what things will be done in the event of PPH. Sometimes bleeding postpartum can happen quite quickly, making urgent action necessary by your care providers.
First, medications to help your uterus contract will be given, probably by an IV if you have one inserted already, but sometimes by injection into the thigh. These medications do work quickly and sometimes that is all that is needed. One medication is inserted rectally (misoprostol), which can be a surprise to women and feel intrusive, but is effective in treating PPH.
If bleeding continues, your midwife or doctor may look quickly to see if the bleeding is coming from a tear or if the placenta looks like it is missing a piece. They may need to insert a hand into the vagina and up into the uterus to feel for tissue, placenta, or clots. They may also need to help slow down bleeding by compressing your uterus with one hand on your abdomen and one hand internally, pressing the uterus together (called bimanual compression). These internal interventions can cause discomfort and be distressing during a time you were hoping to be cuddling a newborn. Thankfully, they are usually short and effective at stopping bleeding. You can ask for pain medication if you are having too much discomfort, or nitrous oxide (if available) may also be useful during this time. If tears (lacerations) are causing the bleeding, your provider should repair them quickly. A medication called tranexamic acid that helps your blood to clot more effectively may be used in this situation of heavy bleeding from a tear.
Some people have symptoms of excess bleeding after birth like lightheadedness, dizziness, headache, feeling your pulse race or pound in your chest. Getting up out of the bed for the first time after birth can also cause low blood pressure and some women can faint, so it’s really important you have a care provider or nurse with you when you get up, or if you are feeling lots of dizziness.
Replacing fluids by drinking or IV will be important now as well as eating iron rich foods. Some people experience more fatigue after PPH in the early postpartum period and may benefit from a blood transfusion or an IV iron infusion. If you are having lots of symptoms before going home, be sure to discuss adequate treatment before discharge.
In some extreme cases, breastfeeding can be affected by PPH, so if you have concerns be sure to talk to a lactation specialist.
by Elise N. Erickson, PhD, CNM
Oregon Health and Science University
Dr. Elise Erickson PhD, CNM is an assistant professor at Oregon Health and Science University. Her research focuses on the physiology of parturition, the intersection between the social environment and perinatal health and predicting labor onset. She additionally studies the function of oxytocin throughout the perinatal period. This includes studies of physiologic and epigenetic variation as well as differences in pharmacologic response and short and long-term consequences of oxytocin administration. She has received funding from the NIH as well as local and national foundation sources. She teaches perinatal physiology at OHSU and is an active member of the faculty clinical practice.
