Vaginal bleeding after childbirth can affect new mothers in different ways.

In this article, we look at the different types of bleeding you could experience after having your baby, also known as postpartum bleeding.

In particular, we discuss abnormal types of vaginal bleeding after childbirth and what makes one woman likely to develop severe bleeding problems.

Types of Vaginal Bleeding After Childbirth

After having your baby, you can expect some degree of normal vaginal bleeding called lochia.

Lochia is a bloody fluid made up of blood, mucous, placental tissue and some parts of the womb coming away.

You can expect to have lochia after birth, and the loss from the vagina can continue for 3 to 6 weeks as your womb heals and returns to its usual shape and size.

Lochia is your body’s way of removing excess blood and material from your womb.

During your pregnancy, the lining of your womb grows thicker to support the baby and placenta.

What’s Normal Lochia

Normal lochia changes from dark red (first 3-4 days), pinkish brown (from day 4 – day 10) and whitish yellow (from day 10 – day 28).

In the first 4 days after your baby, you will notice the lochia consists of small clots, and you could have pain from womb contractions); bright red blood is not unusual.

Your lochia can get lighter over time; it might also get heavier and look more red when you breastfeed.

This is because Oxytocin, the hormone responsible for your milk’s ‘let-down’ or flow, also affects your womb – causing it to contract at the same time.

Abnormal Bleeding After Delivery

Abnormal bleeding can develop AT ANY time from delivery and up to 12 weeks after birth.

However, it is MOST common in the first 24 hours (this is also known as Primary Post Partum Haemorrhage).

Primary Postpartum Bleeding

Heavy bleeding happening during this time (within 24 hours of delivery) is abnormal.

This is generally regarded as bleeding over 500mls and can be quite severe.

Now, although we can expect a degree of heavy bleeding around the first day(s) after childbirth, it should not be:

• Blood clots bigger than a plum/guava/agablumo fruit.
• Bleeding that soaks more than one sanitary pad an hour and doesn’t slow down or stop
• accompanied by –
  • Blurred vision
  • Chills
  • Clammy skin
  • Rapid heartbeat
  • Dizziness
  • Weakness
  • Nausea
  • Faint feeling

Developing ANY symptoms like any of these, whether you are at home or in the hospital, must be brought to your doctor/midwife’s attention immediately!

Prompt attention to these symptoms will allow monitoring, investigation and treatment for the condition and reduce the risk of death.

Secondary Postpartum Bleeding

Abnormal bleeding happening after 24 hours of delivery and up to 6 weeks later is known as secondary postpartum bleeding.

Most often, this happens from womb infection; and sometimes, it may have left the hospital.

These terms, primary or secondary postpartum haemorrhage, are useful to help doctors consider the possible causes that may lead to abnormal bleeding.

Main Causes of Abnormal Vaginal Bleeding after Childbirth

Most times, postpartum bleeding happens because the womb muscles do not contract enough to control the bleeding at the areas where the placenta attaches to the womb. Another term for this is uterine atony. 

Other causes of abnormal bleeding after childbirth include:

• having parts of the placenta left behind (retained) in the womb.
  • It could also happen in a condition known as placenta accreta – when the placenta grows too deeply into the uterine wall.
• Experiencing trauma of some form in childbirth (like a cervical laceration, uterine rupture or another rare but extremely serious condition known as uterine inversion).
  • In a uterine inversion, the womb turns inside out and may happen from pulling on the umbilical cord or pushing on the top of the womb before the placenta has come away.
• Clotting disorders – women with these conditions struggle to stop bleeding naturally.

Are You at Risk of Bleeding After Birth?

Now let’s look at conditions that could make one or other of the bleeding causes we have discussed above more likely to happen.

We can place them easily in two groups: those that happen before childbirth or in labour.

Conditions that develop before childbirth

• Experiencing postpartum bleeding in a previous pregnancy ·    
• Having a BMI (body mass index) of more than 35   
•  If you delivered 4 or more babies before your current pregnancy
•  Carrying twins or triplets in your current pregnancy  
•   Being of South Asian ethnicity
• Having an abnormality of the placenta:
  • a low-lying placenta (placenta praevia)
  • the placenta coming away early (placental abruption)
•   Developing Pre-eclampsia and/or high blood pressure
• Anaemia

Conditions associated with your labour

Most of the time, the problems linking postpartum bleeding that happens after labour occurs from weak/tired muscles of the womb, which cannot contract and stop blood flow.

Here are some of them:

• Delivery by Caesarean Section · 
• Induction of Labour
  • Labour induction increases the risk that your uterine muscles won’t properly contract after you give birth (uterine atony), which can lead to serious bleeding after delivery. We’ll talk a little more about this in the next segment.
• Retained placenta     ·  
• Episiotomy (a cut given in the vagina to help delivery of the baby), or a perineal tear
• An assisted delivery using forceps or ventouse (vacuum) to help deliver the baby
• Being in labour for more than 12 hours ·   
•  Having a big baby (more than 4kgs/9lbs)
• If you have your first baby when you are more than 40 years old
• Very rarely, the type of surgical process used in delivering your baby can increase the possibility of bleeding afterwards, as can having an infection following surgery.

What is the Induction of Labour?

Induction of Labour (IOL) is the stimulation of uterine contractions during pregnancy before labour begins on its own in order to achieve a vaginal birth.

A healthcare provider might recommend labour induction for various reasons, primarily when there’s a concern for a mother’s health or a baby’s health.

However, it can also be ELECTIVE – this is when you choose to have the procedure and do not medically need the intervention.

Consider the following medical reasons you may require IOL:

• Post-term pregnancy. In this case, you’re approaching two weeks beyond your due date, and labour hasn’t started naturally.
• Prelabor rupture of membranes. Here, your water has broken, but labour hasn’t begun.
• Chorioamnionitis. In this condition, you have an infection in your uterus. Of priority will be the delivery of your baby.
• Fetal growth restriction. This describes the poor growth of your baby during pregnancy. The estimated weight of your baby is less than the 10th percentile for gestational age.
• Oligohydramnios: meaning – there’s not enough amniotic fluid surrounding the baby.
• Gestational diabetes – a condition when you develop abnormal blood sugar control during pregnancy.
• High blood pressure disorders of pregnancy. This generally describes: 1) a pregnancy complication characterized by high blood pressure and signs of damage to another organ system (preeclampsia), 2) high blood pressure that was present before pregnancy or that occurs before 20 weeks of pregnancy (chronic high blood pressure), or 3) high blood pressure that develops after 20 weeks of pregnancy (gestational hypertension).
• Placental abruption. Your placenta peels away from the inner wall of the uterus before delivery — either partially or completely.
• Certain medical conditions, such as kidney disease or obesity.

Preventing Bleeding After Childbirth

Your doctors and midwives know how high the risk of bleeding is after childbirth and will routinely take measures to prevent it from happening.

Below is a list of some steps they may take:

• If you have a vaginal birth, injecting the drug Syntocinon (a synthetic form of the natural Oxytocin) into your thigh just as the baby is born can help reduce blood loss.
  • This injection helps the placenta to come away from the wall of your uterus normally.
• After delivery of your placenta, it’s important to check for any tears. Your doctor will check the tissue carefully for any tears to repair them promptly.
  • They will stitch them promptly to reduce blood loss if they are bleeding heavily.
• If you have a caesarean section, you will get a Syntocinon injection into the drip in your vein.
  • Following this is the delivery of your placenta through the wound.
• If you choose to breastfeed, your midwife will encourage you to begin as soon as possible – this helps produce more of the hormone Oxytocin (a natural form of Syntocinone) to contract the womb.

How To Treat Vaginal Bleeding After Childbirth

When it happens, especially within the first 24 hrs after your delivery, and is severe, the midwife or doctor may take the following steps:

• Massage your womb through your abdomen to stimulate a contraction
• Give you a second injection to help your uterus contract. This injection may make you feel like vomiting.
  • You will be given an injection during labour and after the baby is delivered to make the womb contract. It also helps in the faster delivery of the placenta and reduces the risk of heavy bleeding afterwards.
  • We give a second injection if we think the womb did not contract well enough after the first – sometimes, it may be added to an infusion.
• Put a catheter (tube) into your bladder to empty it, as this may help your uterus to contract better.
• Put a drip into your arm, and take some blood for testing.
• You might need Oxygen if the bleeding is quite severe – given through a nose mask or nasal prongs.
• It may be necessary to perform bi-manual compression. This is where the doctor or midwife puts one hand inside your vagina and the other hand on your abdomen; and then squeezes the uterus in between in an attempt to slow the bleeding.
• Check to make sure all of the placenta has come out.
  • If there are any missing pieces still inside your uterus, you may need to have them removed. (This will usually be done in an operating theatre with an anaesthetic medicine to put you to sleep).
• Examine you to see whether you have any cuts or tears that require stitches – especially if bleeding continues after your uterus has contracted. Your blood pressure, pulse and temperature will be checked regularly.  You may breastfeed if you wish.

What Happens if Heavy Bleeding Continues…

When you might need surgery

• If you have lost a lot of blood, you are likely to feel dizzy, lightheaded, faint and/or nauseous.  This is why you may be given oxygen (and possibly a drip for extra intravenous fluids).
• Drugs will be used in an attempt to help stop the bleeding, and you may be given a blood transfusion and fluids to help your blood clot.
• If the bleeding continues, you may be taken to the operating theatre so the doctors can check for the cause of the haemorrhage. 
• You will need an anaesthetic for this.  (Your partner will usually stay in the delivery room with your baby and will be kept informed about how you are and what is happening).
• There are several procedures the doctors may use to control the bleeding during surgery:
  • They may plant a ‘balloon’ inside the womb to put pressure on the bleeding vessels. (This is usually removed the following day).
  • An abdominal operation (laparotomy) may be performed to stop the bleeding.
  • Very occasionally, a hysterectomy (removal of the womb) is necessary.  This would only be considered if other measures have not controlled the heavy bleeding. Once your bleeding is under control, you will either be transferred back to the labour ward, or you may be transferred to an intensive care or high-dependency unit.  You will be monitored closely until you are well enough to go to the postnatal ward/area.

Can You Prevent Bleeding After Childbirth?

Sometimes there are not many things you can do to PREVENT bleeding after childbirth that we have described in this article.

But in some cases, there are conditions you ignore that expose you and make your risk of bleeding greater:

• Failing to treat Anaemia – please take it seriously; take your tablets; report any symptoms of anaemia:
  • (Very tired, feeling drained, feeling SOB, pounding headache, tingling sensation, dizziness, rapid heartbeat.)
• Treating any high blood pressure very seriously using both medicines and non-medical options.
• Maintaining a healthy weight before pregnancy
• Some drugs like SSRs (antidepressants) can increase the risk of postpartum bleeding (Some studies suggest that the use of SSRIs and related drugs during the last month of pregnancy may increase the risk of abnormal bleeding after childbirth).

Helpful Tip

Avoid these till you are fully recovered from childbirth

• Exercise: It takes weeks to recover fully after childbirth, especially if you had surgery.
  • Delay high-impact activities like body attack/cardio/running for several weeks.
  • You should wait till your bleeding stops before starting an exercise program
  • If your bleeding restarts, it suggests you may be doing too much exercise
• Sex: After a vaginal birth, allow your body to heal completely till you have regained your strength and any tears or wounds from an episiotomy have settled.
  • You should also think bout birth control before resuming sexual activity.
• Driving: If you’ve had a C-section, you should avoid strenuous exercise and activities like driving until your wound fully recovers.

In many countries with limited health facilities or resources, vaginal bleeding after childbirth is still quite common, causing serious illness or death.

One of the reasons we think this is the case is due to the difficulty of getting the right care when you need it – poor equipment or poor services.

But other reasons are that many women and their families do not realise the risks and how to recognise them.

More Reading:

• Keeping New Mums safe; bleeding after delivery – Pt 2
• Keeping New Mothers Safe Postpartum Haemorrhage Symptoms – Part 3
• 5 Reasons You Didn’t Know For Vaginal Bleeding After Sex
• Keeping New Mothers Safe from Postpartum Haemorrhage – Part 1
• 4 Common Risk Conditions for Early Pregnancy Bleeding
• Shop New Mums Healthcare

Editing by AskAwayHealth Team

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