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Perhaps one of the most useful things you can do when deciding if you would like to have your baby at home after experiencing a postpartum haemorrhage (PPH) after a previous birth, is exploring what may have happened during your labour and birth that could have increased your risk. Ineffective uterine contraction is the main cause of PPH with the other causes being perineal/cervical damage, or in very rare cases, blood clotting disorders.

There is evidence which concludes that the use of synthetic oxytocin either to induce labour or to speed the process up (augment) is associated with a significantly higher risk of PPH. Other factors linked to increased likelihood of PPH are retained placenta, epidural anesthesia, episiotomy, forceps or vacuum assisted deliveries. With this in mind, many women may be able to see a potential reason that they experienced PPH. Other than retained placenta, none of the factors above are issues or procedures associated with home birth. A recent study showed that women classed as ‘low risk’ who gave birth in a hospital setting, were much more likely to experience a PPH which may be due to the increased risks of all of the aforementioned factors which occur in a hospital setting.

Oxytocin friendly environment Many practitioners believe that appropriate management – be that active or expectant – of the third stage of labour to be the key to preventing PPH. Even ‘low risk’ women giving birth at home will be offered ‘active management’ of the third stage of labour. This involves an injection of synthetic oxytocin being administered to the mother shortly after the birth of her baby which (usually) speeds up the delivery of the placenta and stimulates the uterus to contract down very quickly. In a physiological third stage (or expectant management) the injection is not administered and the placenta is allowed to be birthed spontaneously. During this time the mother usually has skin to skin contact with her newborn which facilitates the natural release of oxytocin. The baby’s movements physically massage the mother’s abdomen and breastfeeding or nipple stimulation may occur, all of which encourage the contracting down of the uterus. During both these approaches your midwife will be observing you, your blood loss and carefully checking that your uterus is contracting well and advising if a change of approach is necessary.

There may be an increased risk of retained placenta associated with active management of the third stage. One of the benefits of the synthetic oxytocin used in active management, is that when administered it can contract the uterus quickly if a PPH starts to occur. Ensuring an ‘oxytocin friendly’ environment is maintained will reduce the risk of bleeding. The same environment that is conducive to birthing in; private, warm, dimly lit, quiet and calm is required to birth the placenta too.

Further reading on PPH and the third stage of labour

Comparing the odds of postpartum haemorrhage in planned home birth against planned hospital birth

Third Stage Info

Midwife Thinking article on the third stage – including info on PPH

AIMS: Third Stage Reviewed

Science & Sensibility: On Birth Bleeding – Part 1

Science & Sensibility: On Birth Bleeding – Part 2

Dr Sarah Buckley – Leaving Well Alone: A Natural Approach to the Third Stage of labour