Death during childbirth has been feared throughout time, and dramatized in countless movies and books. Though “childbed fever” was once a major threat (and is still in some parts of the world), the greatest fear most modern women have is of bleeding that will not stop. Postpartum hemorrhage seems terrifying and unavoidable – if you're unlucky, you'd better be where you can get blood transfusions. But is this reality? Is it simply a matter of chance that one woman is struck with hemorrhage? Is it unavoidable for her?
The answer to both of those questions is no. Postpartum hemorrhage is preventable – but the reality is that modern, technological birth tends to increase your risk. So how do you prevent it? Keep reading 🙂
Birth is designed to be safe. Before anyone starts arguing about this exception and that exception, let me make it clear that I realize there are exceptions – and I'm sure you do too. But those are exceptions, the minority. It just doesn't happen very often. And if we take care of mamas-to-be, feed them well, and understand how birth is supposed to work, exceptions would truly be rare. Essentially you must step back, sit on your hands, and let mama do her thing. Or, if you're mama, tell everyone to leave you alone!
Why? Birth is no a purely physical process where your body cranks open and the baby pops out. It's not like opening the hood of a car and hauling something out. We may describe birth in very mechanical terms, but it's a process that involves all physiology. And one of the most important aspects of that is hormones.
You've probably heard of oxytocin – it's one of the primary hormonal players in birth. But it's assisted by many other hormones working in tandem. These hormones actually create safety during birth, because they tell the body to do exactly what it's supposed to do1,2. For instance, oxytocin tells the uterus to get firm, fast, after your baby is born. And having an undisturbed birth where you gaze into your baby's eyes (again, uninterrupted) once he or she is born promotes oxytocin levels at a lifetime high. They're so high everyone else gets a “contact high” from them! That's just one example.
Now imagine that you're cuddling with your husband and he's looking really handsome. One thing leads to another and you head to the bedroom. Things are going nicely and it looks like it's going to be a lot of fun. Then suddenly the lights come on. Somebody needs to inspect “down there” to make sure all is well. They're checking your heart rate (continuously). They're putting an IV in. Or maybe they just tell you to get in the car and hold on – you'll be somewhere safe for lovemaking in a few minutes!
What does that do to the mood?
Does that sound ridiculous? Or even relevant? It's totally relevant because lovemaking depends on oxytocin, beta-endorphin, a little bit of adrenaline at the right time… the same hormones responsible for how safely (and smoothly) labor moves along. Every once in awhile it's warranted to interrupt birth, but for the vast majority of mothers, interruptions create danger, not safety. Dangers start with “stalled labor,” extra pain, fetal distress, etc. – and often don't end until a mom is bleeding way too much and a baby is isolated away from mom in a sterile environment he or she never expected.
Since undisturbed birth and mama/baby interaction in the first few minutes skyrocket all the hormones that signal all the physical changes the body needs to make, it's scary to mess with that time. And since baby is expecting mama's body to regulate temperature, breathing, heart rate, and even blood sugar levels, it's terrifying to think of what's going on when that biological safety net is ripped away.
The safety features built into birth don't start when the labor hormones do – they actually begin around the 8th week of your pregnancy. That's when your body begins to slowly expand your blood supply. By 28 weeks your blood volume will have increased by around 60% above your pre-pregnancy volume. That's quite a bit of extra blood3.
That blood is actually vital during pregnancy (so vital that pregnancy complications occur when the blood volume doesn't increase). It helps bring nutrients to the placenta and the baby, maintains the lake of blood the placenta draws on, ferries waste away from your baby and through your own filtration systems – and it maintains your body, prepares you for breastfeeding, and prepares the uterus for birth. Among other things 😉
After your baby is born, however, that blood supply isn't needed. It quickly mobilizes and moves out. If you've already had a baby, you probably remember having to pee tons in the first day or two postpartum, then things return to normal. Urination is part of the way all that extra fluid moves. Labor and birth happen before the point of heavy peeing – so all that extra blood is on board throughout labor, and essentially becomes instantly unnecessary after your body pushes baby out.
In other words, you have a lot of extra blood on board and you can lose a bit of it. All moms are different, and some moms can lose more blood with no effect while another mom may feel really woozy after relatively little blood loss. But all well-nourished moms with fully expanded blood supplies have quite a bit of extra blood when baby is born. Before I talk more about why “well-nourished” is so key, lets put some things in perspective:
You know that you lose blood during childbirth. But we as humans tend to fear blood overall – and pregnant women have been taught (incorrectly, as you've seen) that bleeding after birth is dramatic and often uncontrolled.
That's not true.
In fact, the amount of blood you lose during a vaginal birth tends to average around a pint (about 500ml or 500cc)4,5,6. If you're picturing a pint jar and thinking “that's a lot!” I can understand where you're coming from – so let me offer another perspective:
When you donate blood, you give about a pint.
During blood donation, around 474ml of blood is taken7. This is from typical adults – who have no extra blood supply (like a pregnant woman's does). Sometimes a few crackers and some juice are needed when the donating person feels a little “woozy” – but nobody panics.
During a cesarean section, a woman loses about double the amount of blood she does during a vaginal birth – around a quart or 1000ml/1000cc's. Again, this is expected and “normal” – though it is at this level that textbooks show that women may begin to show systemic signs of blood loss (they may experience shock signs)8. Again, all women are different and some react differently to losing blood – but remember:
Giving birth means losing about the same amount of blood as when you donate blood – and you already have an extra 2.1 quarts of blood on board!
Lets get back to that extra blood and your body now:
I mentioned “well-nourished” mothers above because nutrition is a key. Volunteer midwives and obstetricians working in poverty-stricken 3rd world countries often see a lot of emergencies because the mothers are close to starving. Their bodies, their placentas, and their babies are not getting what they need. Stress is also incredibly high for these mothers, and sometimes adequate nutrition can't overcome chronic stress.
So this is obviously not good news – and seeing true nutritional change for these women is a great hope of mine and probably yours. But the good news for you in this is that those moms have high rates of complication and need for emergency obstetrics because of something you can prevent.
The bad news for you, personally, is that many women do not understand this, and that being poorly nourished can and does happen even to prosperous “first world” women. It doesn't have to, though. Here's why nutrition is important enough for you to stand up and pay attention:
A well nourished uterus works well. This seems like common sense but I'm doubtful that it is. The pregnancy diet advice given to most women today is criminal and comes close to prescribing malnutrition. A woman who is getting plenty of nutrients, calories, etc. is sending nutrients to her uterus, which is growing at a rapid rate.
The uterus has a huge job to do – as I mentioned above, it needs to keep baby inside, hold the “lake of blood” the placenta draws from, and it needs to practice for labor. Then it needs to actually work during labor to pull back and thicken to create the powerful force that pushes baby out. And, of course, after baby is out it continues firm up, shears the placenta off, seals off the vessels that supplied the placenta with blood, and contracts down to a normal postpartum size.
That's a lot of work for one muscular organ, and it needs food – good food – to build up to that.
Nutrition is what's responsible for helping your blood volume expand. Again, expansion starts in the 8th week of your pregnancy and completes around the 28th week. You start your pregnancy with about 3.5 quarts of blood. By week 28, you have 5.6 quarts of blood on board. That is a 60% increase in your blood supply! That increase is maintained throughout the rest of your pregnancy.
It's vital to supply nutrients to your growing baby, and to nourish the placenta. A well-nourished placenta continues to function well throughout pregnancy. All that extra blood is also bringing plenty of nutrients to your uterus. Plus it helps your body to process nutrients, filter wastes, and do everything else it needs to do for the upkeep of you and your baby.
Many care providers don't truly understand the incredible changes a pregnant woman's body undergoes in every single system of the body. The metabolic system and circulatory system change in massive ways, primarily to facilitate this blood volume expansion. Because care providers don't understand how important nutrition is to these changes, they often give advice that's not just bad, it's dangerous.
Research has shown that trying to limit weight gain is dangerous for essentially every pregnant woman (even if she is obese during her pregnancy)9. It robs the baby and mom's body of nutrients. Every pregnant woman needs her blood volume to expand.
That expansion happens primarily due to two nutrients: dietary protein and sodium. Dietary protein in the only thing the body can use to create albumin. Sodium is, of course, salt. Albumin and sodium are both crucial to maintaining osmotic pressure in the blood stream. Essentially that means that those nutrients keep fluid in the blood, where it's supposed to be (rather than having it leak out into the tissues, where it causes swelling). Some light swelling is normal during pregnancy, but severe swelling indicates the blood volume is trying to expand and cannot – usually due to inadequate diet3.
Calories are really important, too. If the body doesn't have enough calories, it starts to break down protein for energy instead of using the protein to make albumin.
So protein, sodium, and calories are vital to blood volume expansion – and a wide range of vitamins, minerals, and other nutrients are needed to nourish your baby, placenta, uterus, and your body.
Being well-nourished is the most important thing you can do to prevent postpartum hemorrhage during pregnancy.
I recommend the Brewer diet, and cover the how's, why's, and common misconceptions in detail in my online Great Pregnancy class (opens in a new tab).
Okay, I covered diet in the section above, and that's truly the biggest thing you can do during your pregnancy to prevent postpartum hemorrhage.
I also covered why undisturbed birthing and guarding those first few moments with baby are so very vital. All of those things together create an incredible, natural protection from postpartum hemorrhage.
There are other things you can keep in mind, too.
Stress Relief: Stress has multiple negative effects during pregnancy, and it tends to sap nutritional stores. Have you ever noticed that, no matter how well you're eating, you're more likely to get sick when you're stressed? It just saps nutritional reserves. Plus stress tends to make it harder to focus on your nutrition. Stress interferes with the natural hormonal flow of pregnancy and birth, and can greatly increase the chances of complications and problems during your birthing time.
Take the time to seriously evaluate stress in your life. Get rid of stressors that are within your control. It may be time to cut back on commitments, do some advance planning to relieve stress with running your household, or delegate work out to team members at work.
You should also build routines into your life to counteract stress. Try simple things like:
These help you break the cycle of stress and replace it with “calm and connection.” All of that boosts your oxytocin levels, too10!
And don't be afraid to ask for help if you need it 🙂
Dates: I'm not talking about dates with your man (though that would relieve stress). I'm talking about the date fruit. Dates are extremely rich in nutrients, but they're extremely beneficial late in your pregnancy11. Women who ate six dates a day from 36 weeks until birthing dilated more quickly, had intact membranes (water hadn't broken) more often, and needed induction far less frequently (96% went into labor spontaneously) compared to the control group which ate no dates12!
Plus research showed that women who were given dates to eat experienced significantly less postpartum bleeding over women who received a Pitocin injection13.
It looks like most of the studies used dried dates – so grab your dates and eat up! They may be a great snack to keep on hand for labor, too 😉
Eating during labor is important. You can probably guess why: an exhausted muscle cannot do what it's supposed to do. If you've been laboring for many hours, you need food to maintain energy, and your uterus needs it too. I cover more about the “whys” if this in my article on how to handle a long labor (opens in a new tab). Dates, juice, honey, etc. can all give energy and a “pick me up” that gives the uterus the burst of power it needs.
You should also drink to thirst, because dehydration can cause weak contractions, too. But you also want to be sure you're peeing frequently. A full bladder causes problems with the uterus because it can't do its work with the bladder in the way. This can slow or stall labor before baby is born. And after it can be a big cause of postpartum bleeding. Makes sure you're making your way to the bathroom frequently.
Let your body push. This is also called physiologic pushing and it follows along with the “undisturbed birth” we talked about above. Your body is actually primed for what's knows as the “fetal ejection reflex” – widely taught by obstetrician Michel Odent14. He observed that when a woman is undisturbed, her body will usually push the baby right out (no coaching needed).
Many moms in my online birthing class ask me if this means not pushing at all. I have experienced the fetal ejection reflex in my last three births and while I can say my body was doing the pushing on it's own (no way I was stopping it), I generally felt compelled to push too. So from personal experience, I think you tend to lend a push to your body 😉 But the uterus is clearly pushing baby out all on its own. And remember, baby is working with this too.
This physiologic pushing avoids stressing you or the uterus out, and it maintains normal oxygen supply to the uterus (and the baby), rather than the unnatural effects of forced and sustained pushing without natural breathing patterns (usually this unnatural pushing is ” Valsalva Manuever” style).
And, again, having your baby skin-to-skin, and undisturbed during the birth of the placenta and beyond is important. Midwife and midwifery instructor Carla Hartley calls this “no hatting, no patting, no chatting.” Michel Odent says “don't wake the mother!” (from her “labor land” state of being). And midwife Gail Hart notes that calm, peace, and quiet are the needed conditions for the safety of birthing.
Gail Hart also notes that leaving the cord unclamped is very important, because it allows baby's blood to flow into baby, rather than being forced back up into your uterus15.
There may be times when extra bleeding occurs, and proactive action (such as manually massaging the uterus, eating a piece of placenta, consuming dates, or even administering Pitocin) will stop it. As always, gather knowledge, make the choices that are right for you, and listen to your intuition.
Birth is designed to be safe for mother and baby and has multiple “checks and balances” in place to create and preserve that safety. A skilled care provider will not only know what to do if postpartum bleeding is heavy, she will have the wisdom and the patience to keep her hands off (and mouth closed) so that it doesn't happen to begin with.
And you, gentle mother, can do so much during your pregnancy – from eating a nutrient-dense diet tailored to your pregnancy needs, to planning a birth where the process of birth and your work with your baby will be respected, to making sure that food and drink are on hand for your birthing time.
Like with so many things related to birthing – there is no “luck” involved. You can and do make a big difference in your pregnancy and birth! An ounce of prevention is truly worth a pound of cure.
1. Odent, Michel. “Preventing Postpartum Haemorrhage.” Midwifery Today. Spring 2013: 18-19.
2. Sarah Buckley Gentle Birth, Gentle Mothering Chapter 6
3. http://www.drbrewerpregnancydiet.com/id11.html (accessed 11/10/14)
4. Anne Frye Holistic Midwifery Volume 2 p. 1175
5. Varney's Midwifery, 4th Edition p. 925
6. Maternal and Child Health Nursing p. 656
7. http://www.redcrossblood.org/donating-blood/donation-faqs (accessed 11/10/14)
8. Anne Frye Holistic Midwifery Volume 2 pp. 1174-1175
9. http://wellroundedmama.blogspot.com/2014/08/very-low-weight-gain-or-gestational.html (accessed 11/10/14)
10. Susan Kuchinskas The Chemistry of Connection (the entire book covers this topic!)
12. http://www.ncbi.nlm.nih.gov/pubmed/21280989 (accessed 11/10/14)
13. http://semj.sums.ac.ir/vol8/apr2007/dates.htm (accessed 11/10/14)
14. http://www.wombecology.com/?pg=fetusejection (accessed 11/10/14)
15. Gail Hart: Postpartum Hemorrhage lecture January 7th, 2014