Hemorrhage

Part of Midwifery and Childbirth

Recognizing and controlling life-threatening bleeding before and after childbirth.

Why This Matters

Postpartum hemorrhage (PPH) is the single leading cause of maternal death worldwide, responsible for approximately one maternal death every 4 minutes globally. In settings without blood transfusion capability or surgical intervention, hemorrhage is often fatal once it progresses beyond a certain point. The window between manageable hemorrhage and irreversible shock can be as short as 30-60 minutes.

The good news: most PPH is preventable or controllable with simple, non-surgical interventions if they are applied early. The majority of postpartum hemorrhage is caused by uterine atony — the uterus failing to contract after placenta delivery, leaving blood vessels at the placental site open. Uterine massage and early breastfeeding (which releases oxytocin) prevent most atony-related hemorrhage.

The birth attendant who recognizes hemorrhage early, responds systematically, and maintains focus under pressure saves lives with only their hands and available herbs.

Definition and Classification

Normal blood loss: Up to 500 mL at vaginal delivery. The body compensates for this through normal mechanisms.

Postpartum hemorrhage (PPH): Blood loss exceeding 500 mL after vaginal delivery.

Severe PPH: Blood loss exceeding 1,000 mL. Requires urgent, aggressive management.

Estimated blood loss is consistently underestimated — often by 30-50%. If you think she has lost 500 mL, she may have lost 750-800 mL. Err on the side of treating more aggressively.

The Four T’s: Causes of PPH

Understanding cause guides treatment:

Cause	Description	Frequency
Tone	Uterus not contracting (atony)	70-80% of PPH
Tissue	Retained placenta or fragments	10-15%
Trauma	Tears, lacerations to birth canal	5-10%
Thrombin	Clotting failure	Rare

The management of each cause differs. Identifying the cause as quickly as possible directs the right intervention.

Step-by-Step Response to PPH

Step 1: Call for Help

Do not manage hemorrhage alone if any assistance is available. You will need: someone to maintain uterine massage, someone to position and monitor the mother, someone to prepare and administer herbal treatments, someone to maintain the airway and monitor consciousness.

Step 2: Bimanual Uterine Massage

This is the first and most important intervention for atonic PPH.

External uterine massage:

1. Feel the uterus through the abdomen — it should be at or below the navel, round, and firm.
2. If it is soft and boggy (not firm), it is not contracting.
3. Cup the uterus in both hands through the abdominal wall. Apply firm, rhythmic massage in a circular motion.
4. The uterus should firm up within 30-60 seconds.
5. If it firms up, maintain the massage for several minutes, then check — does it stay firm, or relax again? If it relaxes, massage again.
6. Continue checking every 5-10 minutes.

Bimanual compression (for severe atony): One hand inside the vagina (in a fist), pushing upward against the lower uterine segment. One hand on the abdomen pushing downward. The uterus is compressed between the two hands. This is more invasive and requires clean hands. It is used when external massage alone is insufficient.

Step 3: Uterotonic Agents (Oxytocics)

These agents stimulate uterine contraction.

Breastfeeding: The single most effective natural oxytocic. Put the baby to the breast immediately. Suckling releases endogenous oxytocin within minutes, causing uterine contraction. This is why early skin-to-skin and breastfeeding are important even when things seem normal.

Nipple stimulation (if baby cannot feed): Manual or oral stimulation of the nipple releases oxytocin. Have the mother or attendant stimulate the nipple continuously.

Herbal uterotonics:

Shepherd’s purse (Capsella bursa-pastoris): The most widely used traditional herbal hemostatic for PPH. Contains compounds that promote uterine contraction and have vasoconstrictive properties. Prepare a very strong infusion or tincture. Administer immediately and continue every 15 minutes.

Yarrow (Achillea millefolium): Strong tea — 2 tablespoons per cup. Tannins and other compounds that reduce bleeding. Give every 15-30 minutes.

Blue cohosh (Caulophyllum thalictroides) or black cohosh (Actaea racemosa): Traditional North American uterine stimulants. Strong preparations — use carefully. Overdose risk is real. Use only if shepherd’s purse and yarrow are unavailable.

Note: Herbal uterotonics are significantly less effective than pharmaceutical oxytocin (Pitocin), misoprostol, or ergometrine. They are a support measure, not a replacement. Apply all other measures simultaneously.

Step 4: Identify and Treat the Cause

Check the uterus (Tone): If the uterus is boggy — atony is the cause. Continue massage and oxytocics.

Check the placenta (Tissue): Is the placenta delivered? Is it complete? A retained placenta or fragments prevents uterine contraction. If placenta is not yet delivered and the woman is bleeding, attempt delivery by controlled cord traction (with counter-pressure, only if cord is intact). If fragments appear missing from the placenta, manual exploration may be needed — insert a clean hand into the uterus and sweep out retained tissue. High infection risk; this is a last resort.

Check for tears (Trauma): Inspect the perineum, vagina (as visible), and cervix (if examined) for lacerations. Significant tears bleed visibly and continuously from the wound site. Apply firm pressure. Large tears require suturing — if suture materials and skill are available. Otherwise, apply prolonged firm pressure with a pad.

Check blood consistency (Thrombin): Clotting failure presents as blood that does not clot — it remains liquid and does not form a gel in a container. If this is present, it indicates a serious systemic problem (often following prolonged hemorrhage or severe pre-eclampsia) that is beyond non-surgical management.

Step 5: Manage Hypovolemic Shock

If the mother is losing large amounts of blood, her cardiovascular system will begin to compensate and then fail.

Signs of shock progression:

• Rapid pulse (above 100, then above 120)
• Pale, cold, clammy skin
• Decreasing blood pressure (later sign)
• Confusion, reduced consciousness (serious)
• Loss of consciousness (critical)

Response to shock:

1. Position: lay her flat, elevate legs 15-30 cm (increases blood return to the heart and brain). Do not use Trendelenburg (head-down) — this position compresses the diaphragm and makes breathing harder.
2. Keep warm — shock victims lose body heat rapidly.
3. Oral fluids if conscious and not vomiting — oral rehydration solution, water, broth.
4. Keep her awake and talking — monitor consciousness.

Oral rehydration: Blood loss is replaced in part by oral fluid only slowly. It is not the same as IV fluid replacement. Oral fluids will not rapidly correct blood volume loss. The priority remains stopping the bleeding.

Prevention of PPH

The majority of PPH is preventable:

1. Active management of third stage: Controlled cord traction after signs of separation (reduces third-stage duration). Uterine massage after placenta delivery.
2. Early breastfeeding: Immediately post-delivery.
3. Inspect the placenta for completeness.
4. Know the risk factors and have medications ready if at risk (prior PPH, multiple pregnancy, large baby, prolonged labor).
5. Shepherd’s purse tincture ready for immediate administration to any high-risk birth.

Time Is Blood

A woman in PPH loses approximately 50 mL of blood per minute from atony. At this rate, dangerous blood loss occurs within 10-20 minutes. Every second of delay in recognizing and responding to hemorrhage directly increases mortality. Have your response plan rehearsed before every birth — not just high-risk ones.