09/19/2026
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ASK THE MIDWIVES: Postpartum Bleeding
Warning… this post may ruffle some feathers. 🫣😬
Another question from our resident 16-year-old question generator, and this is a BIG one.
“What if there’s too much bleeding?”
Postpartum hemorrhage is probably one of the most common fears families have when considering birth outside of a hospital. Our answer is never, “Don’t worry, that probably won’t happen.” We trust birth, but we’re not delusional. Hemorrhage happens. Sometimes there are risk factors we can identify ahead of time, and sometimes it happens unexpectedly and very quickly.
Our answer is: we prepare for it.
Actually, preparing for hemorrhage starts long before there is blood on a chux pad. It starts during pregnancy. We pay attention to nutrition, iron and anemia, hydration, placental location, previous hemorrhage, multiples, how stretched the uterus may be, medications, clotting concerns, and other things that might change someone’s risk or their ability to tolerate blood loss. We continue that assessment through labor because what happens during labor matters too.
One thing people sometimes don’t realize is that bleeding after birth is NORMAL. The placenta has been attached to the uterus for months with a tremendous blood supply flowing through it. Once it separates, all of those blood vessels need to stop bleeding. The uterus has a pretty incredible physiological system for doing exactly that. The muscle contracts and retracts around those vessels, essentially creating its own living ligatures.
So our goal isn’t zero bleeding. Our job is to recognize when normal postpartum bleeding is becoming abnormal bleeding and, just as importantly, figure out WHY.
We aren’t staring at a measuring container waiting for some magical number to give us permission to be concerned. We’re watching the trend and the whole person. We’re watching uterine tone, the amount and pattern of bleeding, the placenta, vital signs, Mom’s color, mental status, and symptoms. Is she dizzy? Pale? Weak? Is her pulse climbing? Is her uterus firm or boggy? Has the placenta separated? Could there be retained tissue? Is the bleeding actually coming from trauma rather than the uterus?
The same amount of blood loss doesn’t necessarily mean the same thing for every person either. Someone who enters labor well nourished, well hydrated, and with a great hemoglobin may tolerate blood loss very differently from someone who began labor significantly anemic, dehydrated, exhausted, infected, or otherwise medically depleted.
This is one of the reasons individualized care matters so much. We’re caring for a person, not treating a number.
So what are we actually doing during those first minutes after birth?
Most of the time, after a normal physiological birth, our goal is to protect the hormonal process that is already happening. Those first minutes aren’t simply a waiting period between the birth of the baby and the birth of the placenta. Mom, baby, uterus, placenta, cord, and hormones are still very much in transition.
When everyone is well, baby goes directly skin-to-skin and stays there. We keep Mom warm. We lower the lights. We keep voices quiet, protect privacy, minimize people moving around, and try not to suddenly turn a peaceful birth room into Grand Central Station because there is finally a baby to look at.
Mom gets to touch her baby, smell her baby, kiss her baby, talk to her baby, and nurse when they’re ready. Even that almost universal instinct to bury your face in your newborn’s head and breathe them in may be part of the sensory and neurohormonal conversation happening between Mom and baby. Touch, smell, warmth, skin-to-skin contact, ni**le stimulation, breastfeeding, privacy, safety, and uninterrupted closeness all support the maternal oxytocin system.
And oxytocin isn’t only about bonding.
Oxytocin is also part of the physiology helping the uterus contract after birth and control bleeding from the placental site. So when we protect those first moments, we aren’t choosing bonding instead of safety. Supporting normal bonding and supporting normal postpartum physiology can be part of the SAME thing. That is one reason we try very hard not to unnecessarily interrupt it.
Assessments still happen. We are watching Mom and baby very closely. We’re just trying to work around Mom and baby rather than making Mom and baby work around us.
We also generally leave Mom, baby, cord, and placenta connected. We don’t routinely clamp the cord at one minute, three minutes, or simply because baby has started breathing. We allow the cord to complete its transition, becoming white, limp, and no longer pulsing. And even after that happens, there usually isn’t any particular hurry to cut it. We keep the cord intact even during resuscitation.
In our practice, it is very common for the cord not to be cut until AN HOUR OR MORE after birth.
There’s something beautifully practical about that too. Keeping the cord intact naturally keeps baby right there with Mom instead of immediately beginning the cycle of cut the cord, move the baby, weigh the baby, measure the baby, dress the baby, pass the baby around, and somehow turn the first hour after birth into a very tiny staff meeting. Unless there is a reason to do otherwise, most of that can wait.
And while Mom and baby are snuggling, we’re waiting for the placenta.
REALLY WAITING… We aren’t watching the clock at ten minutes thinking, “Okay placenta, your turn. Let’s go.” In our practice, it is very NORMAL for the placenta to be born somewhere around 30 to 60 minutes postpartum. Sometimes it comes in ten minutes. Sometimes everyone is nursing, snuggling, eating a snack, and admiring the baby until eventually somebody remembers, “Oh yeah…there’s still a placenta in there.”
If Mom is stable, her uterus and bleeding are reassuring, and there is no clinical reason the placenta needs to be out RIGHT NOW, we’re comfortable giving her body time to finish what it started.
Once we see signs that the placenta has separated, we encourage Mom to follow her body’s urge to push it out. We may help her sit upright, squat, get onto the birth stool or toilet, or otherwise change positions and let gravity join the birth team. We also generally avoid pulling on an unseparated placenta to hurry things along. The cord is attached to the placenta. It is not a convenient little handle.
Waiting does NOT mean ignoring. We’re assessing the entire time. Has the placenta separated? Is the uterus firm? What is the bleeding doing? How is Mom feeling? Are her vital signs reassuring? Is there anything about the pregnancy, labor, birth, or third stage that changes our level of concern?
This is what we mean when we talk about protecting physiology.
Sometimes good midwifery means knowing exactly when to intervene. Sometimes it means recognizing that everything is working beautifully and having enough patience to leave it alone.
We RARELY actively manage the third stage, and we rarely routinely give Pitocin after birth. And yes, we know that may be different from what you’ve heard. You may have heard that “the evidence” supports routine active management of the third stage because it reduces postpartum hemorrhage. Evidence absolutely matters to us. But evidence also has CONTEXT.
Much of the evidence shaping routine obstetric practice comes from hospital populations and hospital systems. That doesn’t make it bad evidence, and it certainly doesn’t mean we ignore it. But evidence gathered in one population, under one set of circumstances, with one combination of interventions cannot automatically be assumed to apply identically to a different population and setting.
A low-risk community birth population experiencing largely physiological labor is not automatically interchangeable with a hospital population that may include induction, augmentation, epidurals, operative births, cesareans, and other interventions or risk factors.
Evidence should inform care, but it shouldn’t relieve us of the responsibility to actually READ the evidence. We want to know who was studied, what their baseline risk was, what else was happening during those births, what outcomes were measured, and whether those findings apply to the individual person sitting in front of us.
There’s also a bigger philosophical question here for us…
We have a hard time accepting the idea that an intervention should be applied indiscriminately to nearly 100% of a healthy population because we begin with the assumption that their bodies cannot reliably keep them safe without it. Pregnancy, birth, placental separation, uterine contraction, breastfeeding, and the immediate postpartum hormonal transition are not pathological processes. They are normal human physiology.
That absolutely does NOT mean physiology never goes wrong. It does. Women hemorrhage, sometimes quickly and catastrophically. That is precisely why we carry medications, train for emergencies, have multiple trained people at births, and watch so carefully after a baby is born. But pathology existing does not automatically make normal physiology pathological.
If someone has risk factors that change the equation, if something about pregnancy or birth has introduced additional risk, if bleeding is increasing, or if the uterus simply isn’t doing what it needs to do, our threshold for intervention changes. Sometimes Pitocin is absolutely the right intervention.
What doesn’t make sense to us is beginning with the assumption that essentially every healthy person needs a synthetic hormone immediately after birth because her own physiological mechanisms cannot be trusted to maintain normal postpartum hemostasis.
And when an intervention is being applied routinely to almost everyone, we think we should be asking more than, “Can this reduce one outcome?” We also want to know who was studied, what their baseline risk was, what other interventions were occurring, what the short-term tradeoffs might be, what the longer-term effects might be, what we haven’t studied yet, and whether the absolute benefit looks the same in a low-risk person having an undisturbed physiological birth.
That isn’t rejecting evidence. We think it’s taking evidence seriously enough to ask better questions.
And here’s where we may irritate a few of our fellow midwives… 😘
We strongly disagree when we hear people say there are no potential harms or downsides to routinely giving Pitocin after birth.
Pitocin is a medication. A VERY useful medication. Sometimes a lifesaving medication. We carry it, we use it, and when someone is hemorrhaging, we are incredibly grateful it’s sitting in our birth bag. But “this medication can prevent or treat hemorrhage” and “there are no potential consequences to giving this medication universally” are two very different statements.
Those first minutes after birth are one of the most hormonally complex transitions in human physiology. Natural oxytocin isn’t simply involved in making the uterus contract. The oxytocin system is involved in lactation, maternal adaptation, stress regulation, bonding, and the enormous neuroendocrine transition happening between Mom and baby.
There are studies that have raised questions about associations between synthetic oxytocin exposure and breastfeeding, newborn sucking behavior and oxytocin regulation, and postpartum mood. The research is NOT conclusive. Some studies have found associations, others haven’t, and some findings point in the opposite direction. Many are observational, and an especially important limitation is that much of this research involves Pitocin used during labor rather than a single prophylactic postpartum dose.
Those limitations matter. We cannot responsibly take that research and announce that Pitocin causes breastfeeding problems, interferes with bonding, or causes postpartum depression. But we also can’t take incomplete and conflicting evidence and somehow turn that into proof that there are NO potential effects.
Sometimes “we don’t know yet” actually means WE DON’T KNOW YET. Science is occasionally very inconvenient that way.
For us, that uncertainty matters when we’re talking about universally administering a synthetic version of a hormone during one of the most hormonally complex transitions in human physiology, particularly when Mom is stable, her uterus is firm, her bleeding is normal, baby is skin-to-skin, and her body is doing exactly what it is supposed to be doing. That is VERY different from someone who is hemorrhaging.
If bleeding starts increasing, “physiology first” absolutely does NOT mean we stand around admiring physiology while Mom loses blood. This is where the quiet midwives suddenly become very busy midwives. We start assessing and responding at the same time.
We’re immediately asking WHY she is bleeding. One framework we use is the 4 Ts: Tone, Tissue, Trauma, and Thrombin. Is the uterus boggy and not contracting effectively? Is there placenta, membranes, or clots preventing it from contracting? Is the uterus firm but Mom is still bleeding, making us think about a laceration, hematoma, uterine inversion, or other trauma? Could there be a clotting problem? We’re also thinking about things like a full bladder interfering with uterine contraction and the whole physical and emotional picture surrounding the birth.
Then we respond to what we’re actually seeing. That might mean changing Mom’s position, getting her out of the tub, keeping her warm, encouraging breastfeeding or ni**le stimulation, helping her empty her bladder, using our hands to massage the uterus, removing clots, helping the placenta deliver when appropriate, using herbs, addressing trauma, starting an IV, giving fluids or medications, providing oxygen when appropriate, calling EMS, and preparing for transfer. Sometimes a whole bunch of those things are happening at the SAME TIME.
Our usual approach is physiology first, then our hands and herbs, then medications as needed. But that is not a rigid little staircase we insist on climbing while someone is actively hemorrhaging. The more serious the situation becomes, the faster things happen and the more interventions happen simultaneously.
Sometimes skilled physiological midwifery looks like sitting quietly in a dim room while Mom smells her baby’s head and her placenta releases on its own. Sometimes it looks like our hands doing bimanual compression while someone else is preparing medication, another person is getting IV fluids running, and EMS is already being called. Both require skill, and knowing when to move from one to the other may be one of the most important skills we have.
We aren’t afraid of Pitocin. We’re afraid of causing a disruption of physiology that isn’t fully understood and it negatively impacting the families we serve.
If the benefits of Pitocin outweigh the potential downsides for the person standing in front of us, we use it. If Mom is hemorrhaging, we can not prioritize protecting the hormonal blueprint while she loses too much blood. We use our hands. We use herbs when appropriate. We use medications. We stabilize. We call for more resources. We transfer when she needs a level of care beyond what we can provide.
We also don’t wait until someone is crashing to start thinking about transfer. Part of being prepared for emergencies in community birth is recognizing when the trajectory is moving beyond what we can safely manage and getting additional resources moving EARLY. We have spent years building a trusting and collaborative network so that in our most vulnerable moments we can work as a team to manage complications effectively.
Our hemorrhage training isn’t just memorizing which medication treats uterine atony. We practice recognizing hemorrhage, figuring out WHY someone is bleeding, assigning team roles, communicating clearly, using our hands, preparing medications and IV supplies, recognizing shock, stabilizing Mom, calling EMS, and continuing treatment while preparing for transport.
The baby being born is not when the midwife’s job is over. In many ways, those first minutes after birth are some of the moments when we are watching Mom the closest. We may look calm, we may be admiring mamas and their beautiful babies, but there is a WHOLE lot of midwife brain happening in the background.
That is the balance we keep coming back to in midwifery: protect physiology first, continuous assessment always, and act without delay when physiology becomes pathology. We don’t believe every normal birth needs to be treated as though an emergency is already happening. But we also don’t wait for an emergency to happen before figuring out what we’re going to do.
Want us to go deeper? Ask us how we recognize hemorrhage, what causes it, what herbs we use, what’s actually in our hemorrhage kit, how we decide when to use Pitocin, what bimanual compression is, what happens with a retained placenta, when we call EMS, why we leave the cord intact, or what the research actually says about active management and synthetic oxytocin.
And as always, your question doesn’t have to be about bleeding. Pregnancy, labor, birth, postpartum, babies, home birth, birth center birth, midwifery, or that slightly awkward thing you’ve been Googling at 2 AM…ASK THE MIDWIVES.
If you’ve wondered it, someone else probably has too.
