How Midwives Prevent and Manage Postpartum Hemorrhage

Written by Igel Cudiera

Postpartum hemorrhage (PPH) means heavy bleeding after birth. The World Health Organization (WHO) describes it as one of the most frequent and life-threatening complications of childbirth, and it can happen to people who have no known risk factors. Most cases happen within the first one to two hours after birth, which is why that time is watched so closely.

This guide explains what PPH is, how midwives work to lower the risk, what happens if heavy bleeding occurs, and which warning signs to watch for after you go home.

If you are bleeding heavily after birth, or you feel faint or dizzy, have trouble breathing, or have a pounding or racing heart, call 911. Do not wait for a routine appointment.

What Is Postpartum Hemorrhage?

There is no single definition. Major organizations use different thresholds, partly because they serve different purposes:

• WHO (2025): to decide when to start treatment, WHO recommends acting when measured blood loss reaches 300 mL or more together with any abnormal sign such as a fast pulse or low blood pressure, or 500 mL or more, whichever comes first within 24 hours of birth. WHO calls this a "therapeutic definition," meant to prompt timely treatment.
• Royal College of Obstetricians and Gynaecologists (RCOG): the traditional definition of primary PPH is the loss of 500 mL or more of blood within 24 hours of birth. RCOG describes 500 to 1,000 mL as minor and more than 1,000 mL as major.
• American College of Obstetricians and Gynecologists (ACOG): defines maternal hemorrhage as a cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of low blood volume (hypovolemia), within 24 hours after birth.

These thresholds are for clinicians measuring blood loss. They are not something you can judge at home. The warning signs you can watch for yourself are below.

Heavy bleeding can also happen later. Secondary, or late, postpartum hemorrhage is significant vaginal bleeding that occurs more than 24 hours after birth, and retained placental tissue and infection are its most common causes.

In the US, a national analysis found that about 3.0% of delivery hospitalizations involved PPH, and the rate rose from 2.7% to 4.3% between 2000 and 2019. Worldwide, WHO reports that PPH causes nearly 45,000 deaths each year. ACOG notes that in the US, PPH causes about 11% of maternal deaths, is the leading cause of death on the day of birth, and that 54% to 93% of maternal deaths due to obstetric hemorrhage may be preventable.

Normal Bleeding After Birth vs. Warning Signs

Some bleeding after birth is expected. This bleeding is called lochia, and the NHS notes that it usually stops after 6 to 8 weeks, although it can last longer.

What is usually expected

The ACOG Foundation's Urgent Maternal Warning Signs guidance describes the usual pattern. In the first 2 to 3 days, bleeding is like a period or a heavy period, with cramping that feels like a period. In the first 1 to 2 days, you may pass a few small clots, no bigger than an egg, especially after you stand up. Over the following weeks, bleeding should get less every day and change to a brownish, pinkish, then whitish discharge.

Contact your midwife or provider right away

The ACOG Foundation lists these as urgent warning signs after pregnancy:

• Heavy bleeding, soaking through one or more pads in an hour
• Passing clots bigger than an egg, or passing tissue
• Vaginal discharge that smells bad

The NHS also advises contacting your midwife or doctor if bleeding gets heavier or does not get any less, or if you have a high temperature (over 38°C, about 100.4°F) or tummy pain that gets worse along with bleeding. The ACOG Foundation advises that if you cannot reach your provider, you should go to the nearest emergency room.

Call 911

The NHS advises calling emergency services if the bleeding is sudden and very heavy, or if you feel faint, dizzy, or have a pounding heart, because this could mean a very heavy bleed that needs emergency treatment. ACOG also advises calling 911 for chest pain or if you are coughing or gasping for air after birth.

What Causes Postpartum Hemorrhage?

Clinicians often group the causes of PPH into four categories, sometimes called the "4 Ts":

• Tone: the uterus does not contract well after birth (uterine atony). WHO notes this is the most common cause of PPH.
• Trauma: tears or other injury to the birth canal, a collection of blood (hematoma), the uterus turning inside out (inversion), or the uterus tearing (rupture). Our guide explains how midwives reduce the risk of perineal tearing.
• Tissue: part of the placenta stays inside the uterus, or the placenta is abnormally attached.
• Thrombin: a problem with blood clotting.

Who Is at Higher Risk?

The National Institute for Health and Care Excellence (NICE) lists risk factors that can be identified during pregnancy, including:

• A previous postpartum hemorrhage of more than 1,000 mL, or one that needed a blood transfusion
• Placenta accreta spectrum (a placenta that grows too deeply into the uterine wall) or a low-lying placenta
• Pre-eclampsia
• A low hemoglobin (anemia) at the start of labor
• A BMI above 35
• Having given birth four or more times
• Bleeding during pregnancy or placental abruption
• An overstretched uterus, for example with twins or extra amniotic fluid
• Existing uterine abnormalities, such as fibroids

NICE also lists factors that can arise during labor, such as induction or augmentation of labor, a long first or second stage, infection (sepsis), a very fast labor, an assisted birth with forceps or vacuum, a cesarean birth, shoulder dystocia, and a delay in delivering the placenta.

Risk factors do not tell the whole story. WHO notes that most people who experience PPH have no identifiable risk factors, which is why it says every health worker should be equipped to diagnose and treat PPH at every birth.

How Midwives Help Lower the Risk

Prevention means lowering the chance of PPH and catching it early. It cannot be guaranteed. Here is what current guidance recommends at each stage.

During pregnancy

WHO recommends testing for anemia during pregnancy and daily iron and folic acid supplements for pregnant women, and it notes that anemia can make the effects of blood loss more severe. WHO also recommends that the risks of bleeding and the signs of excessive blood loss be discussed with you during pregnancy, so you can share in decisions about your care.

Your health history matters too. NICE advises that people with risk factors identified during pregnancy give birth in an obstetric unit, where more emergency treatment options are available. Your midwife reviews your history during prenatal care and can explain when a midwife works with an OB-GYN.

During labor and birth

NICE advises continuing to assess risk factors during labor, since some arise only as labor progresses. WHO's PPH guideline also includes perineal care as part of prevention: it recommends techniques to reduce perineal trauma based on your preferences, and it does not recommend routine or liberal use of episiotomy.

Delivering the placenta (the third stage of labor)

The third stage of labor is the time from the birth of your baby to the delivery of the placenta. NICE describes two approaches:

• Active management: routine use of a uterotonic (a medicine that helps the uterus contract), clamping and cutting the cord, and gentle controlled pulling on the cord after signs that the placenta has separated.
• Physiological management: no routine uterotonic, no clamping of the cord until it stops pulsing or the placenta is delivered, and delivery of the placenta on its own or by your pushing.

WHO recommends a quality-assured uterotonic for the prevention of PPH during the third stage of labor for all births. NICE advises that active management is associated with a lower risk of PPH or blood transfusion. NICE estimates that, per 1,000 women, about 68 would have bleeding of more than 500 mL with active management compared with about 188 with physiological management, and about 13 would need a blood transfusion compared with about 35. Active management was also linked with more side effects such as nausea, vomiting, headache, high blood pressure, and readmission for bleeding (about 186 compared with 90 per 1,000).

A Cochrane review found that active management probably reduces blood loss of more than 500 mL, but the evidence on severe bleeding of more than 1,000 mL was very low certainty. If you prefer physiological management, NICE advises your care provider to discuss your level of risk so you can make an informed decision, and to support your choice. NICE also advises changing to active management if heavy bleeding occurs or the placenta is not delivered within 1 hour.

The first hours after birth

Because most PPH happens in the first one to two hours, close monitoring matters. WHO recommends that blood loss be measured objectively, for example with a calibrated drape, rather than estimated by eye, because visual estimation is unreliable and usually underestimates blood loss. ACOG agrees that measuring blood loss is more accurate than estimating it, while noting that its effect on outcomes has not yet been demonstrated.

WHO also recommends regular checks of the uterus for all women to make sure it is firm and well contracted. The first hour is especially important, with checks ideally every 15 minutes, typically continuing through the first one to two hours.

What Happens If Postpartum Hemorrhage Occurs

Management means recognizing heavy bleeding quickly and treating it. Clinicians follow their training and local protocols. This section is a general overview of what you can expect, not a guide to treatment.

Recognizing it early

Early recognition is a large part of treatment. In a large trial in 80 hospitals in Kenya, Nigeria, South Africa and Tanzania (E-MOTIVE), early detection using a calibrated drape together with a treatment bundle meant PPH was detected in 93.1% of patients, compared with 51.1% with usual care. Severe bleeding (1,000 mL or more), surgery for bleeding, or death from bleeding occurred in 1.6% of patients, compared with 4.3% with usual care.

First-response treatment

WHO recommends a first-response bundle of care once PPH is identified. It includes:

• Uterine massage
• A medicine to help the uterus contract
• Tranexamic acid, a medicine that helps reduce bleeding
• Intravenous (IV) fluids
• Examining the birth canal to find the source of bleeding
• Escalating care if bleeding continues

WHO recommends that tranexamic acid be given early, within 3 hours of birth, and research has found that its benefit decreases the longer treatment is delayed. NICE similarly advises calling for help, starting immediate treatment, continuously assessing blood loss and your condition, identifying the source of the bleeding, and arranging transfer to obstetric-led care.

When hospital care is needed

Some bleeding does not respond to first-line treatment. WHO's guideline describes further treatments for these situations, some of which depend on immediate access to surgery and blood products, which are available in hospitals. Blood transfusion, procedures, and surgery may be needed. Timely escalation and transfer are a key part of care, and our guide explains how a hospital transfer works.

Postpartum Hemorrhage at a Home Birth or Birth Center

The safety of any birth setting depends on appropriate risk assessment, qualified care, the resources available, emergency planning, and timely transfer or escalation when higher-level care is needed. WHO notes that its diagnostic criteria can apply to home and community births, although adaptations may be needed to measure blood loss and monitor vital signs.

Research on low-risk births in different settings shows mixed results, and it does not show that any one setting is safer for everyone:

• In a Dutch study of low-risk women, PPH was less common with planned home birth than planned hospital birth for people who had given birth before (19.6 compared with 37.6 per 1,000), but there was no difference for first births (43.1 compared with 43.3 per 1,000).
• In the Birthplace in England study, as summarized by NICE, blood transfusion among low-risk women was 4 per 1,000 for planned home births and 8 per 1,000 for planned obstetric unit births for people who had given birth before, and 12 compared with 16 per 1,000 for first births.
• In a US study of nearly 18,000 community births, 15.9% had blood loss over 500 mL and 3.3% had 1,000 mL or more. PPH was more likely in states with barriers to midwifery practice, and the authors suggested that improved legal access to uterotonic medication would likely reduce it.

NICE also advises that maternity and ambulance services have strategies in place to respond quickly if PPH happens in any setting. If you are considering a home birth, ask your midwife how they monitor bleeding, what they bring to a birth, and when they would recommend transfer. Our article comparing home birth and hospital birth covers these questions in more depth, and you can read about what a planned home birth involves.

After You Go Home

Bleeding problems are not limited to the hours after birth. Late bleeding can occur more than 24 hours after birth, including after you are home, so keep watching for the warning signs described above, and do not wait for a scheduled visit if you notice them. The CDC advises getting medical care immediately for urgent maternal warning signs and telling any provider that you were pregnant within the last year. Our postpartum care page explains how follow-up works after your baby is born.

Questions to Ask Your Midwife About Bleeding After Birth

• Do I have any risk factors for postpartum hemorrhage, and how do they affect where I should give birth?
• How will you check for anemia during my pregnancy?
• How do you manage the third stage of labor, and what are my options?
• How do you measure and monitor bleeding after the birth?
• What do you bring to a birth, and what would happen if I started bleeding heavily?
• When would you recommend transfer to a hospital?
• Which warning signs should I watch for after I go home, and who should I call?

These build on the question about postpartum hemorrhage in our list of questions to ask when choosing a midwife.

This article is general educational information about postpartum hemorrhage. It is not medical advice and does not replace evaluation and individualized care from your midwife or physician. No approach can guarantee that postpartum hemorrhage will not happen, and every pregnancy and birth is different. If you are bleeding heavily or think you need urgent care, call 911.

Sources

• World Health Organization, FIGO and ICM. WHO recommendations: Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage (October 2025).
• World Health Organization. Global health agencies issue new recommendations to help end deaths from postpartum haemorrhage (October 2025).
• American College of Obstetricians and Gynecologists. Postpartum Hemorrhage, Practice Bulletin No. 183 (2017, reaffirmed 2024).
• American College of Obstetricians and Gynecologists. Quantitative Blood Loss in Obstetric Hemorrhage, Committee Opinion No. 794 (2019, reaffirmed 2025).
• American College of Obstetricians and Gynecologists. Postpartum Pain Management (last reviewed August 2022).
• Royal College of Obstetricians and Gynaecologists. Prevention and Management of Postpartum Haemorrhage, Green-top Guideline No. 52 (2016).
• National Institute for Health and Care Excellence. Intrapartum care, NICE guideline NG235 (2023, last updated June 2026).
• ACOG Foundation. Urgent Maternal Warning Signs.
• Centers for Disease Control and Prevention. Urgent Maternal Warning Signs (2024).
• NHS. Early days (last reviewed January 2026).
• Begley CM, Gyte GM, Devane D, McGuire W, Weeks A, Biesty LM. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews 2019, CD007412.
• Gallos I, Devall A, Martin J, et al. Randomized trial of early detection and treatment of postpartum hemorrhage. New England Journal of Medicine 2023.
• Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage. Lancet 2018.
• Corbetta-Rastelli CM, Friedman AM, Sobhani NC, et al. Postpartum hemorrhage trends and outcomes in the United States, 2000–2019. Obstetrics & Gynecology 2023.
• de Jonge A, Mesman JA, Manniën J, et al. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. BMJ 2013.
• Erickson EN, Bovbjerg ML, Cheyney MJ. Factors affecting third-stage management and postpartum hemorrhage in planned midwife-led home and birth center births in the United States. Birth 2020.
• Paladine HL, Blenning CE, Strangas Y. Postpartum Care: An Approach to the Fourth Trimester. American Family Physician 2019.
• Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. American Family Physician 2017.