Haemorrhage during childbirth or postpartum

After birth, once the baby has been delivered, the placenta gradually detaches and is expelled. This phase is accompanied by moderate bleeding that stops mechanically once the uterus begins to contract. Some bleeding after delivery is therefore normal — it is excessive bleeding that can be dangerous.

More than 500 mL of blood lost 

In France, postpartum haemorrhage (PPH), also referred to as haemorrhage of delivery, is defined as uterine blood loss exceeding 500 mL (2 cups) within 24 hours of delivery.

However, in many countries, uterine blood loss must exceed 1000 mL (4 cups)[1].

For example, when donating blood, between 420 and 480 ml is collected. For most healthy individuals, this is generally well tolerated.

Furthermore, the increase in blood volume during pregnancy (approximately 1,250 ml) provides a degree of protection against the effects of postpartum bleeding.[2]

When does postpartum haemorrhage occur? 

It usually occurs at the time of delivery or within 2 hours of birth. However, it can occur later, more than 24 hours and up to 12 weeks after delivery.

A not-so-rare and dangerous phenomenon

Postpartum haemorrhage is estimated to affect between 2 and 10% of women giving birth. This figure varies across studies and countries. According to a recent study in the Netherlands involving 2.5 million women between 2000 and 2013, the rate of haemorrhage at delivery increased from 4.1% to 6.4%[3].

Fortunately, it is often mild and managed promptly in most cases. Yet it remains the leading cause of maternal mortality in France.

The main causes of haemorrhage during childbirth include:

- A uterus that does not contract or contracts poorly (uterine atony). This accounts for approximately 70% to 80% of cases.

- Retention of part of the placenta that has remained attached to the uterus. As the uterus has not been completely emptied, retraction does not occur. The remaining tissue must be removed to stop the bleeding.

- A tear or an episiotomy, which must be "repaired" to stop the bleeding

- A coagulation disorder: this may be pre-existing or arise during pregnancy (low platelet count, pre-eclampsia…) [4], although it is considered to be the least common cause.

More than half of cases are unpredictable, and there is no reliable way of anticipating them.

There are, however, risk factors that may be worth knowing about and discussing with your midwife or gynaecologist. Some factors can be identified before birth, whilst others will only be identified during labour [5],[6],[7],[8],[9].

Postpartum haemorrhage: factors identified before birth 

- Having a placenta that covers a large part of the cervical opening (placenta praevia), which increases the risk of part of the placenta being retained

- Fibroids in the uterus

- More than 5 births

- A twin pregnancy

- High blood pressure during pregnancy

- Having a sister or mother who experienced PPH

- A previous birth involving a caesarean section or uterine surgery

- Having a condition called polyhydramnios (too much amniotic fluid)

- Being <20 or>35 years old

- Being a first-time mother, especially if having a baby later in life

Postpartum haemorrhage: factors identified after birth 

- A third- or fourth-degree perineal tear

- Part of the placenta remaining attached to the uterine cavity for a period of time after birth

- Having delivered with forceps/ventouse

- Medically induced labour, in particular with a synthetic oxytocin drip, which can cause the uterus to "exhaust" itself. Labours with very rapid and frequent uterine contractions are also a contributing factor.

- An episiotomy

- Delivering a "large" baby (>4.5 kg)

Several factors can be taken into account in the prevention of postpartum haemorrhage.

Avoid unnecessary inductions

Induction with synthetic oxytocin and prolonged use of this synthetic hormone are considered risk factors for uterine atony. [10]

Indeed, this synthetic hormone causes uterine contractions that are more frequent, longer, and stronger than those naturally produced by the body, thereby increasing the possibility of the uterine muscles becoming "exhausted".

Place your baby skin-to-skin immediately after birth and breastfeed

Placing the baby skin-to-skin immediately after birth may in particular promote oxytocin production. Skin-to-skin contact also facilitates the establishment of breastfeeding. In turn, breastfeeding stimulates the breasts, which causes the uterus to contract, helping it return to its normal size more quickly and thereby reducing bleeding.

According to a randomised study published in 2018 involving 108 births, breast stimulation has similar effects to synthetic oxytocin treatment during the third stage of labour [11]. This synthetic hormone is often used to reduce bleeding. Furthermore, mothers who received breast stimulation (using a breast pump in the study) reported less post-partum pain and had a better birth experience overall.

According to a Cochrane review, breast stimulation before labour to initiate contractions could prevent significant bleeding to a certain extent. The rate of postpartum haemorrhage with stimulation was 0.7% vs. 6% without stimulation [12].

Researchers were able to measure oxytocin levels in saliva before and after breast stimulation, demonstrating that natural levels did indeed rise afterwards. [13]

Improve management

To estimate blood loss, healthcare professionals use visual estimation. According to studies, on average, smaller volumes of blood are often overestimated, while more significant losses tend to be underestimated [14]. However, it is possible to collect all bleeding during the third stage of labour (excluding the placenta and membranes), in order to measure losses more accurately.

The WHO (World Health Organisation) has issued recommendations to reduce the risk of haemorrhage. Consultation among experts led to the definition of two sets of care to be implemented in healthcare settings. The "first response" bundle includes uterotonic agents, isotonic crystalloids, tranexamic acid, and uterine massage. The set of measures for refractory PPH then includes compression measures (aortic or bimanual uterine compression), non-pneumatic anti-shock garments, and intrauterine balloon tamponade. Awareness, training, teamwork, monitoring, communication, and the use of best clinical practices were defined by the WHO as key elements of management [20].

According to a recent 2023 study, haemorrhage prevention may be possible by monitoring certain parameters in the patient [21]. The intervention included a calibrated blood collection drape for early haemorrhage detection and a set of first-response treatments (uterine massage, oxytocin infusion, tranexamic acid, intravenous fluids, examination and monitoring). Postpartum haemorrhage was thus detected in 93.1% of patients in the intervention group and in 51.1% of those who did not receive this follow-up and these interventions. This resulted in a 60% reduction in severe haemorrhage. 

Stock up on foods naturally rich in vitamin K

Many believe that pregnant women with a vitamin K deficiency may be at greater risk of postpartum haemorrhage. Without vitamin K, blood cannot clot normally, which may mean delayed clotting or, in some cases, no clotting at all. 

Coagulation disorders account for only a minority of cases of haemorrhage during childbirth. A study on postpartum women was unable to show a link between vitamin K supplementation during pregnancy and PPH [15]. But stocking up on foods naturally rich in vitamin K can only do you good!

The estimated daily intake is 60 µg for adults, pregnant women, and breastfeeding women, and 50 µg for children. Traditionally, we consumed more foods rich in vitamin K, particularly K2, such as fermented foods and egg yolks, but this is less common nowadays [16]. The body stores very little vitamin K, so reserves are constantly being replenished [17].

You will get your daily dose from: 10g of kale, 15g of parsley, 25g of spinach, 30g of Brussels sprouts, 45g of broccoli, or 110g of sauerkraut [18]. 

Nettle tea is also a source of vitamin K (100g of cooked nettle provides 498 mcg of vitamin K), as well as other minerals such as calcium, iron, and magnesium [19]. Steep 2 to 5g of dried nettle leaves for around ten minutes, taking care to place a lid on the cup. Drink 3 times a day towards the end of pregnancy!

En général, les personnes qui ont eu des hémorragies lors de leur accouchement mettent plus de temps à se rétablir. Certains traitements peuvent être administrés à la clinique ou à l’hôpital. Parlez-en avec votre professionnel de santé (sage-femme, gynécologue) pour vous faire accompagner.

Il est possible que vous souffriez d’une carence en fer à la suite de la perte sanguine, soit d’une anémie ferriprive.

Le « baby blues » ou « dépression post partum » peut toucher n’importe qui, mais vous aurez plus de chance de souffrir d’une dépression post partum après une hémorragie à l’accouchement. Certains symptômes sont identiques avec une anémie ferritine et il peut ainsi être difficile de les distinguer. Il ne faut donc pas hésiter à en parler avec votre médecin ou sage femme pour vous faire aider. Pour plus d’info sur le baby blues, consultez notre article écrit par une psychiatre.

Se reposer

Il est important de se reposer le plus possible.

Faire le plein de fer

Même si vous prenez des suppléments de fer, votre alimentation doit rester une source de fer importante. Certaines personnes ayant subi une HPP racontent notamment avoir eu très faim au cours des semaines suivantes.

Des idées :

- Si vous mangez de la viande, prenez un peu de viande rouge

- Les produits de la mer comme les huîtres sont également riches en fer

- Les lentilles sont également riches en fer

- Le beurre d’amande : Deux cuillères à soupe de beurre d'amande contiennent notamment autant de fer qu’une portion de poulet !

Astuce : consommer des aliments avec de la vitamine C pour ainsi aider votre corps à absorber le fer. Par exemple un jus de citron sur votre poisson, du persil sur vos lentilles, des fraises avec du beurre d’amandes.

Nos vitamines post partum Post essentials font également complément de vitamine C. 

Il est également possible de prendre un complément de fer si besoin.

Parler de votre accouchement

Il peut être important de parler de votre expérience avec votre sage-femme ou gynécologue, et de ne pas hésiter à lui poser toutes les questions sur ce qui s’est passé, comment ils ont réagit et quel a été le traitement reçu.