Postpartum hemorrhage (PPH) is losing two (500 mL) or more cups of blood in 24 hours surrounding birth.  Losing four (1000 mL) or more cups of blood is an emergency PPH and warrants medical treatment.  While ACOG may have changed their definition of PPH from 500 mL to 1000 mL, they aren't using holistic methods for treatment and we need to remember this when we're preparing for home birth, especially one with lower resources.  Furthermore, one mother may have symptoms of shock when only losing 1 cup of blood, where another mother may feel fine at 8 cups loss.  The way someone is bleeding, regardless of the amount, can also indicate when to treat.  If it looks like someone turned on a facuet, you have minutes, not hours, to manage this.  Thankfully, we don't see this kind of bleeding with well-nourished mothers often.  But, we need to always anticipate the hours after we leave and the weeks of breastfeeding and healing.  We need to use estimate blood loss amounts, not just mom's reaction, when we are applying treatment.  This is especially true when we are using a holistic approach to treatment that includes nutrition and herbs.

Imagine if we waited until everyone got into an emergency state to help them.  How much valuable time would we use to gently nurture the body back into balance with love and herbs and nutrition?  Four+ cups blood loss may not be effectively treated with herbs and nutrition alone, and then we would be at the mercy of only medication and clinical care and traumatized mothers. Additionally, the cause of PPH is not always the same and can’t always be treated in the same way as other types of PPH or other types of bleeding. Herbs are usually effective for mild to moderately heavy bleeding that is slow, over many hours.  God decides if and when any of these methods work, but He also gives us education on how to use our remedies well.  PPH is far more complex than a nosebleed, cut, or your menses, so be careful to think you can treat it in the same way you would treat a basic first aid case at home, too.

Health is going to be the first line in preventing and stopping excess bleeding.   Mom and Dad’s bond and environment are going to be the second approach.  Your birth team and the tools (including medical backup) are the last technique.  There is equal importance with a nourished body and a loving environment that prevents and heals PPH.  If a mom feels safe and loved and has been very well nourished before and during birth, her body will have everything it needs to prevent and manage most blood loss from birth.  The uterus cannot contract well without adequate nourishment, or without enough oxytocin (the hormone that rises when moms feel very safe and very loved).

Next, it is very important to assess the amount, how, and especially why bleeding is occurring in PPH.  Not all remedies work for all types of bleeding when it comes to childbirth, but there are a few ways we can assess.   When teaching new midwifery students and practicing skills, we discusses the Four T's of postpartum bleeding.

TONE (Uterine Tone/Atony)

The uterus must contract firmly to close the open bleeding vessels after birth and remain firm through rest and nourishment.  80% of postpartum hemorrhages occur from poor uterine tone.  Gently feeling the uterus, we can tell if it is less firm, larger, or in the wrong location than it should.  Anything inside, or blocking, the uterus can prevent it from contracting well, even having a full bladder.  Bleeding from low tone can look like quick continuous gushing or gushing with movement or stress, especially around separation and birth of the placenta.  Classically, this occurs with a mom that is tired, undernourished, or overwhelmed.  Sometimes blood that is filling inside the uterus starts clotting and doesn’t come out, so it isn’t visible, but it can feel firm because the clots push on the inside of the uterus.  Using our hands we may be able to wiggle or compress the uterus to expel clots and slow this bleeding until other methods take over.  Though, hard mashing of the uterus may increase bleeding. Uterotonics (herbs and medications that increase contractions, some which work on the ocytocin receptors to trigger contractions in the uterus) are used to treat uterine atony.  Treatments for uterine atony include ones such as Cotton Root Bark, Birth Root, Angelica, Pitocin (synthetic oxytocin), Misoprostol, and Ergometrine.

It is important to note that oxytocic treatments, such as oxytocic herbs and Pitocin, are only appropriate for uterine atony of the upper 2/3 of the uterus.  The further down the uterus you get, the less oxytocin receptors  there are, and hardly any in the cervix.  All of this helps with cervical dilation so that the contractions aren't working against decent of the baby and dilation and effacement.  This also helps prevent the cervix from closing up too soon after the birth to allow the placenta to come when it is ready and to allow bleeding and clots to be expelled.  However, this means that if the placenta attachment site is in the lower 1/3 of the uterus, you will anticipate heavier bleeding even without treatments (because endogenous oxytocin won't be as effective here), and these oxytocic treatments won't be very effective if bleeding is heavy.  Herbs, however, do have a different effect than the oxytocin alone does because they also are working nutritionally; though, they are generally not effective for severe PPH because they won't work fast enough (and many practitioners don't dose them correctly).

TISSUE

Retained tissue can cause uterine atony, but until the tissue is out, the bleeding won’t slow.  Placental tissue or clots can cause trickle bleeding (which can be hard to notice) or gushes in the first hours or weeks after birth.

We generally treat PPH from retained tissue the same as uterine atony: trying to contract the uterus harder.  However, sometimes, the inside of the uterus needs to be suctioned or scraped out to remove the tissue so the uterus can contract.  It only takes a sliver of retained tissue to cause heavy bleeding.  It is worth repeating here that if the placenta site is in the lower 1/3 of the uterus, bleeding will likely be heavier and require more tools to treat if there are retained tissues, especially from a partially detached placenta.

TRAUMA

Tears or hematoma inside or outside of the vagina, or hematomas, can causing a slow PPH, or more rarely may be deep enough or through an artery to cause very rapid PPH.  Holding compression on bleeding vessels may stop bleeding from tears until the tissue can be sutured.  Treating uterine atony may help, though herbs and medications that are astringent or repair tissue such as Yarrow, Plantain, Seaweed, Ceylon Cinnamon, Yunnan Baiyao, or Cayenne may help with very mild bleeding from tissue trauma.  Herbs, like cinnamon and cayanne, that shunt the blood to the peripheral parts of the body can help buy you a little time in using other methods of treatment because they move blood away from the uterine and vaginal area.  This mechanism can temporarily reduce bleeding while you treat with other methods for all-cause bleeding, including suturing.

THROMBIN

Blood clotting disorders are rare but can be one cause of heavy bleeding and usually require immediate venous access and blood transfusion.  Blood from a person with low clotting factors will often look thin and watery or may cause numerous micro-clots and bruising.  Occasionally, a slow PPH from undernourishment can be managed with herbs like Shepherd’s Purse, Spirulina, Chlorella, Chlorophyll, and Vitamin K.

No matter why or how you’re bleeding, love, a warm blanket or tea, and electrolytes for fluid replacement are always helpful alongside any other treatment techniques.