Bleeding after birth

How much should I expect? Where does it come from? What’s healthy? What if I had a high blood loss last time – will it happen again?

Losing any amount of blood can look scary. We’re conditioned to feel fear, or at least worry, when we see blood coming from us, and that’s usually a completely fair reaction. In most circumstances bleeding isn’t meant to happen and usually indicates that something is wrong. The only exception (other than after having a baby) I can think of is menstruation and sometimes this can feel quite alarming too.

Over the years I’ve heard a lot of understandable worries from many women about the amount of blood they lost after having a baby. It is equally distressing for birth partners to witness heavy blood loss after birth. I wonder if it would help to understand what is considered ‘normal’ or healthy and what’s not?

The amount of blood lost straight after a baby is born is an estimate. Midwives and doctors are taught ways of assessing how much blood they think has been lost. In the UK, an estimated blood loss (EBL, if you’re looking at your notes) at the time of birth of anything up to 500ml is considered normal and healthy following a vaginal birth. Blood loss following a caesarean birth might be higher and could be up to a litre. In case volume means more in ‘old money’, 500ml is just under a pint, so a litre is coming up to about 2 pints.

Both these amounts might sound alarming. After all, if you were to tip 500ml or a litre of milk across your kitchen worktop it would go a long way. But what you might not know is that by the end of pregnancy, women have around 1.5 litres more blood than they had before they were pregnant. That’s just under 3 pints. Women’s bodies make this extra blood in order to supply their side of the placenta, carrying oxygen and nutrients from the mother’s blood and passing them to the baby’s circulation within the placenta (dead clever, that!). By the end of pregnancy the placenta is pretty big. It ends up about the size of a dinner plate and a good 2-ish cm thick. It is full of crinkles, nooks and crannies so that there is space to contain more blood vessels carrying a higher volume of blood overall than if it were a thinner, flatter organ. The mother’s blood is a bit more dilute than it was before pregnancy so the blood flows easily into all these little nooks. Once the baby is born, the placenta is no longer needed, and all that extra blood that’s been manufactured in the mother’s body also isn’t needed. When the placenta comes away, it leaves a ‘wound’ that needs to heal, which is where most of the blood comes from initially. In addition there will be some blood loss from any tears, an episiotomy cut or a caesarean incision.

In order for the placenta to come away after birth, more contractions are stimulated either naturally or due to an injection of an oxytocic drug (often called syntocinon in the UK, or Pitocin in the US). The placenta is attached to the wall of the womb by blood vessels. The contractions after birth cause the ‘living ligatures’ that wind around and between the blood vessels to clamp down firmly, squeezing the blood vessels closed, so that the placenta can then peel away and be expelled via the vagina, or can be removed via the incision in a caesarean birth. The area where the placenta had been attached to the womb is now somewhat ‘raw’ and needs to heal. It will therefore bleed both at the time of birth, causing the initial blood loss, as well as continuing after the birth. This blood loss that continues after birth is called “lochia” (pronounced lock-ear). Lochia isn’t just blood, although in the first few days after birth it is mainly blood. Gradually its composition changes over days/weeks to include more mucus, different kinds of ‘waste’ cells and cells associated with healing as the mother’s body adjusts to no longer being pregnant.

You might notice contractions in the womb when you put your baby to the breast in the days after birth, as breast feeding produces oxytocin, the natural hormone that helps the uterus to contract back down to its pre-pregnant size and shape. This postnatal oxytocin release also causes the ‘let-down’ reflex when breast-feeding (contracting the breast tissue to enable milk to be carried from where it’s made in the breast to the area behind the areola, where the baby can access it). The oxytocin also helps you and your baby fall in love and bond (and is also stimulated by skin-to-skin contact - and not just in the 1-hour after birth. It's ongoing!). If you find these postnatal contractions uncomfortable or painful you can ask your midwife about taking a pain-killer. Although I’ve described where the placenta was attached as ‘raw’ or a ‘wound’, you shouldn’t notice pain directly from it. If you do, please talk to your midwife or doctor.

Although an estimated blood loss of up to 500ml is considered ‘healthy’ in the UK, some people think that if a bit more than 500ml is lost at the time of birth then there will be less blood loss in the weeks following the birth. In Europe anything up to 1 litre of blood loss at the time of birth is considered usual and wouldn’t normally be cause for concern. This is just because of different medical guidelines, not because French women are biologically any different to British women! Remember, we have all that extra blood by the end of pregnancy and therefore many women can cope with a slightly higher blood loss at the time of birth compared to if they hadn’t been pregnant. This is why, although losing, for example, a litre of blood at the time of birth can feel alarming, most women wouldn’t require a blood transfusion. If you weren’t pregnant, you didn't have a placenta and you hadn’t just given birth, a one-litre blood loss might well require a transfusion because you would have reduced your base amount that you need inside you by a considerable amount.

Some things increase the chance of a heavier bleed at the time of birth. These include an induced labour, a very long labour where the uterine muscles have become ‘tired’ and can’t contract efficiently any more, an instrumental birth using forceps/ventouse, episiotomy (a cut), very low iron (there is some debate about what constitutes ‘low’) or maybe a low platelet count. If you’re planning another baby, having previously had a higher-than-average blood loss, and you’re feeling worried about the possibility of a high volume of blood loss again, you might like to consider what could have contributed to that loss last time. If it’s possible to avoid the contributory factors in a next birth, then there’s every chance that your blood loss could fall within normal/healthy parameters.

Some women are “strongly advised” or instructed that they “must” give birth in a hospital because of a higher-than-average previous blood loss. If you feel that a hospital birth is right for you, then of course you can accept the advice. You might also like to know that it is your right to choose whether you birth at home or in hospital, even if you have previously experienced a high-volume blood loss. If you wish to discuss your situation with health professionals, you might like to ask, “What is the likelihood of a repeat high blood loss if I (for example) decline induction of labour and the resulting long labour and forceps birth that I had last time?” If this kind of scenario was a contributory factor last time and you are able to avoid the same scenario next time, then it seems reasonable to assume that your ‘risk factors’ for a repeat heavy blood loss might be quite low. Of course, your situation may be way more complicated than this. There is no right/wrong decision-making here. Just know that you have the right to make your own decisions rather than to have them made for you. By the same token, you obviously also have the right to choose to take any suggestion or advice that’s offered to you by a health professional. Your baby, your body, your choice.

I hope this helps to clarify why, even if you felt scared and upset at the amount of blood lost at birth, you might not always have seen the same level of concern from health professionals, or experienced remedial action such as a blood transfusion. It’s possible that your blood loss was within the realms of ‘healthy enough’ or, if it was higher than expected, that your body was able to cope with that blood loss better than the next person. Of course, if you are worried or if you feel wobbly, weak or exhausted beyond what you’d expect after just having a baby, then always talk to a midwife or doctor and explain your concerns.

During postnatal check-ups your midwife (with your permission) will always feel your womb by gently touching your belly, just as she did during antenatal appointments. She is checking to see that your womb feels firm and is contracting back down to its pre-pregnant size in a way that she expects. She will also ask you about your blood loss (lochia) so you might like to be prepared to tell her how many maternity pads you’re getting through in a day, what colour the loss is, whether you’ve passed any clots, whether there are any changes in the odour of the loss, if you experience any pain, etc.

To briefly summarise what happens in terms of postnatal vaginal blood loss, you can expect bright red heavy bleeding in the first few days. You are likely to get through a maternity pad in a couple of hours or so and you might pass some clots. Gradually, over time, the lochia changes to a brownish/pinky colour and then to a more creamy colour. The way the lochia changes colour and consistency is similar to what happens when you have a period, but is spread out over a longer amount of time, possibly lasting 4-6 weeks in all. You might notice heavier bleeding if you do anything active (even a bit of light housework), when breastfeeding, or if you’ve been lying down for a while and then stand up. If you notice an offensive smell, tell your midwife or doctor. If the bleeding changes from what you expect, especially if it becomes heavier again or you start to pass large or many clots, tell a health professional. If in doubt, check it out!

You can read more about what to expect in terms of blood loss after birth on the NCT website here: https://www.nct.org.uk/life-parent/your-body-after-birth/bleeding-after-birth-10-things-you-need-know

Make sure you have copious supplies of maternity sanitary pads and that your birth partner, or person looking after you after birth, knows where to find them in the supermarket when you run and out and need more! Maternity pads are best, even though they feel cumbersome. The thin, winged things won’t be enough to begin with anyway and they can also wick so much moisture from the area that it can cause problems with wound healing if you have a tear, cut or any stitches.

OK, so this isn’t perhaps the most light-hearted or delightful topic to think about, but it is a reality of having a baby. My aim has been to help you understand more about what to expect and also to explain something about blood volume, where it all comes from and what you needed it for.

I think that the adaptations that women’s bodies make in order to support and nurture a pregnancy are pretty damn remarkable. The fact that our bodies not only created and held a pregnancy, but also sustained it by making intricate changes to our own circulatory system to supply an organ that didn’t even exist before pregnancy, makes us flippin’ incredible!