Vaginal bleeding is a normal part of the after-birth healing process
Even if your baby is born by caesarean section, you will experience vaginal bleeding after you’ve given birth. This bleeding is known as lochia, which is a combination of mucous, tissue and blood that your womb (uterus) sheds as part of the healing process after you’ve given birth. The blood mainly comes from the area in your uterus where the placenta was attached, but it may also come from any cuts and tears caused during the birth.
50 shades of red
Bleeding will start off heavy just after the birth with a bright red colour. It will generally change to a brownish red colour within a few hours or a few of days. As the flow becomes lighter, the colour will also change through paler shades (lighter red, pinkish red, and then a more beigey colour after a couple of weeks).
Bleeding generally lasts around four to six weeks, but for some of us it can last up to 12 weeks after the birth.
What should you keep an eye on?
In the first few days, you might notice several small clots on your maternity pads which is normal. However, if you’re noticing larger clots, or you’re passing what you think might be more blood than normal (see info on PPH below), make sure to talk to a health professional.
In the weeks that follow, you'll need to keep an eye on the below symptoms that may be signs of a secondary postpartum haemorrhage. Secondary PPH is often associated with an infection.
Feeling shaky, feverish, and generally ill.
Having lochia with an offensive smell.
Heavier than expected bleeding, or bleeding that becomes heavier rather than lighter over time.
Always speak to your GP or health visitor if anything doesn’t feel right.
What is postpartum haemorrhage (PPH)?
Postpartum haemorrhage (PPH) is heavy bleeding after birth. PPH can be primary or secondary:
Primary PPH is when you lose 500 ml (a pint) or more of blood within the first 24 hours after the birth of your baby. Primary PPH can be minor, where you lose 500–1000 ml (one or two pints), or major, where you lose more than 1000 ml (more than two pints).
Secondary PPH occurs when you have abnormal or heavy vaginal bleeding between 24 hours and 12 weeks after the birth.
How could a PPH affect you?
If you lose a lot of blood, you may feel dizzy, light-headed, faint or nauseous. In the majority of cases (whether you are at home, in a midwifery-led unit or in hospital), heavy bleeding will settle with the simple measures – see next section.
A PPH can also make you anaemic (Iron deficiency caused by the blood loss), and worsen the normal tiredness that all women feel after having a baby.
If heavy bleeding does occur, it is important that it is treated very quickly so that a minor haemorrhage doesn’t become a major haemorrhage, which can be life-threatening.
What does treatment for primary PPH looks like?
In the majority of cases, heavy bleeding will settle with the following simple measures:
Massage of the womb through the abdomen (or sometimes vaginally), to encourage it to contract.
Injection of synthetic oxytocin into the thigh to help the womb contract.
Catheter (tube) inserted into the bladder to empty it as this may help the womb contract.
Intravenous drip to give warm fluids.
Perineal stitches if required.
Your care provider will also check to make sure that all of the placenta has come out. If there are any missing pieces still inside the uterus, they may have to be removed; this is usually done in an operating theatre under general anaesthetic.
If you have had your baby at home or in a midwifery-led unit, your midwife will call for assistance and arrange your transfer to hospital. Most of the actions listed above can take place immediately wherever you are.
If you give birth in hospital, your midwife will push the emergency bell to call other members of staff into the room to help. It can happen quickly and people rushing into the room may be frightening for you and your birth partner.
Your care providers should explain what is happening and why throughout.
What if heavy bleeding continues?
If heavy bleeding continues and you have lost more than 1000 ml (two pints) of blood, a team of senior hospital staff will be involved in your care.
Treatment may include:
Medications
Oxygen via a facemask
Drip for extra intravenous fluids
Blood transfusion
If the bleeding continues, you may be taken to the operating theatre to find the cause of the haemorrhage and provide further treatment. You will need an anaesthetic for this. Your partner will be kept informed about how you are and what is happening, and your baby will be cared for. These are very rare cases.
What are the risk factors associated with primary PPH?
The table below shows the risk factors associated with primary PPH. Even if some apply to you, it is important to remember that most women with these risk factors will not experience a haemorrhage after giving birth.
In fact, most women who have a primary PPH have no identifiable risk factors. However, if you do have any of these, you may be advised to have your baby in a hospital setting where there is access to blood transfusion if you need it.
Before labour, risk factors are:
Low-lying placenta (placenta previa)
Placenta coming away early (placental abruption)
Pre-eclampsia or high blood pressure
Taking blood-thinning medication
Blood clotting problems
Anaemia
Growths in or around the womb (e.g. fibroids)
Previous postpartum haemorrhages
A twin or triplet pregnancy
A body mass index (BMI) above 35
During labour, risk factors are:
Induced labour
Caesarean section birth
Forceps or vacuum-assisted vaginal delivery (ventouse) birth
Retained placenta
Episiotomy
Your labour lasted longer than 12 hours
Having a baby that weighs more than 4kg (9lbs)
Having your first baby when you’re over 40 years old
Having a raised temperature during labour
Having a general anaesthetic
What can be done during birth to reduce the risk of a primary PPH?
Avoid unnecessary interventions and create an environment that supports birth physiology and the release of the hormone oxytocin.
You can read a previous post I wrote on conducive birth environment here.
Managed third stage: you'll be offered an injection of synthetic oxytocin (syntocinon or ergometrine) into your thigh just as the baby is born to help reduce blood loss. This injection helps the uterus contract and the placenta to come away from the womb quickly.
If you had an undisturbed straightforward physiological birth, you might want to consider a physiological management of the placenta. Here is a great article from Dr Rachel Reed that explains the different options in detail: An actively managed placenta may be the best option for most women.
If you have a caesarean section, the same injection will be given and your placenta will be removed through the caesarean incision
Assessment for tears and cuts: Once the placenta is born, you will be examined for any tears. If the tears are bleeding heavily, they will be stitched to reduce any further blood loss.
Prophylaxis medication: if you are known to be at high risk for PPH, you may be offered additional medications (just in case) to help reduce the amount you may bleed.
Maternity pads
As you are getting ready for the birth, get maternity pads rather than menstrual pads as they’ll be more absorbent. Describing the number of maternity pads you’re using also gives your midwife a clear picture of how much blood loss you’re experiencing. You can use the maternity pads in conjunction to disposable postpartum underwear which are breathable, more comfortable and have more space in them to hold the pads…
Breastfeeding and postpartum bleeding
Because breastfeeding makes your body release oxytocin which makes your uterus contract, you might release the lochia blood more quickly. This means that the bleeding might be heavier to start with, but it will be the same amount of blood overall.
Photo by Michelle Glenn Photography