Hesperian Health Guides
Check the mother’s physical signs
HealthWiki > A Book for Midwives > Chapter 13: The birth of the placenta: stage 3 of labor > Check the mother’s physical signs
Contents
Bleeding after birth
The main risk to the mother during stage 3 is heavy bleeding.
The mother usually pushes the placenta out soon after the birth. Then the womb contracts (tightens and shrinks) to keep from bleeding too much. If the mother is not bleeding or having other health problems, the midwife can watch and wait while the mother rests and holds and feeds the baby.
But if the mother is bleeding too much, the midwife must take action. Heavy bleeding after the birth can severely weaken the mother or kill her. Around the world, very heavy bleeding after birth is one of the most common causes of death for women.
Most bleeding after birth comes from the place where the placenta was attached. During pregnancy, blood passes through the wall of the womb to the placenta. As long as the placenta is attached, the mother will not bleed. When the placenta is born, the womb must contract quickly to prevent heavy bleeding.
If the placenta has separated, fully or partially, but is still in the womb, it may hold the womb open. Even a small piece of placenta left inside the womb can keep it open and bleeding. To stop bleeding after birth, you must be sure the womb is empty and help it to squeeze into a small, hard ball.
The way you help depends on whether the placenta has come out. If it has, feel if the womb has contracted. If it has not, rubbing (squeezing and massaging) the womb is a good way to make it contract and stop the bleeding.
Rub the womb
For a womb that has not contracted, put your hand on top of the womb and squeeze while you move the same hand in a circle. The womb should get firm and should be in the center of the belly, not off to the left or right. Check the womb every 1 or 2 minutes for a while. If it gets soft again, rub it until it contracts again. Teach the mother and a family member how to check the womb and rub it so it stays firm.
Medicines to help the womb contract
Medicines can also be given to help the womb contract and stop bleeding. Some medicines can be given either before or after the birth of the placenta, such as oxytocin and misoprostol. Pregnant women who give birth at home are sometimes given misoprostol ahead of time to prevent or stop heavy bleeding. But other medicines such as ergometrine cannot be used until after the placenta is born and the womb is empty because it can cause the cervix to close with the placenta trapped inside. See more on medicines to help the womb contract..
Throughout this book we suggest that you care for women in the ways that medical science has proven will save the most lives and cause the least harm.
But medicine is not simple. Experienced, skilled health workers can have conflicting ideas about how to keep people healthy. And lifesaving tools or medicines are not available in many parts of the world.
Many international medical groups recommend that midwives and doctors “actively manage” the 3rd stage of labor. This means:
- giving oxytocin or misoprostol to every woman immediately after the baby is born,
- guiding the placenta out shortly after the birth, and
- checking the firmness of the womb after the placenta is born.
For women giving birth in hospitals, medical studies show that using active management means fewer women bleed heavily after birth. If your health authority says you should actively manage birth in this way, and you are able to do it safely (see below), do so. In this book, though, we describe how to manage the 3rd stage actively only after a problem arises. We do this for several reasons:
- Most women do not bleed heavily after birth so they do not need medicines, and often do not want to use medicines they do not need.
- Giving medicines before the placenta comes out means a midwife must be able, if necessary, to guide the placenta out quickly and completely so the womb can contract.
- Guiding the placenta out by hand is very risky. You might accidentally break the cord or even pull the womb out. If you are far from emergency care, guiding the placenta out by hand may cause problems you are unable to solve. See how to guide the placenta out by the cord.
- Midwives may only have a little oxytocin and few sterile needles. They may need to save the oxytocin they have for women who are actually bleeding. (Misoprostol, which can also treat heavy bleeding and is more available than oxytocin, can also be used for active management when oxytocin is not available.)
Watch for heavy bleeding before the placenta comes
Some bleeding after the baby is born can be OK as long as it stops. But constant bleeding while the placenta is still inside is a serious problem. Bleeding too much after birth is especially dangerous for women who are in poor health or undernourished.
Here are 3 ways a woman can lose too much blood (hemorrhage):
- Fast, heavy bleeding. The mother may lose a lot of blood in a gush all at once, or blood may flow heavily for several minutes. This can quickly make her weak or faint. This is a severe emergency.
- A slow trickle. This kind of bleeding is harder to notice. But any steady bleeding, even just a trickle, is a danger to the mother.
- Hidden bleeding. This bleeding, which collects in the womb or the vagina, is very dangerous and is easy to miss. You may not see the blood, but:
- the woman may feel faint and weak
- her pulse will speed up or slow down
- if she bleeds too long, her blood pressure will drop
- the top of her womb may rise in the belly as it fills with blood
Most bleeding after birth comes from where the placenta was attached to the womb. This blood may be bright or dark, and often thick. Sometimes only part of the placenta has separated and the rest is still attached. This stops the womb from contracting, so the woman keeps bleeding.
Sometimes bleeding comes from a tear in the vagina, cervix, or womb. Usually this bleeding is a constant, slow trickle of thin, bright red blood.
Heavy bleeding, or feeling faint or dizzy after a birth, are danger signs. Rub the womb if it is not firm (see above), have the mother breastfeed, and give oxytocin or misoprostol if you have it (see below). If this does not work and you cannot find the cause of bleeding, get medical help fast.
| To stop bleeding from the womb before the placenta is out |  |
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in the side of the thigh muscle | ||||
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by mouth OR in the rectum | ||||
| The woman should let the pills dissolve under her tongue for 30 minutes and then swallow any remaining parts. If she is feeling nauseous, insert the pills into her rectum. Wear a glove. | |||||
Watch for signs the placenta has separated
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| The placenta has probably separated when there is a small gush of blood and the cord looks longer. |
The placenta usually separates from the womb soon after birth, but it may not come out for some time. Signs that the placenta has separated from the womb are:
- A small gush of blood comes from the vagina. A gush is a handful of blood that comes out all at one time. It is not a trickle or a flow.
- More of the cord has come out. When the placenta separates, it drops down closer to the vaginal opening, pushing more of the cord outside the mother's body.
- The womb rises. Before the placenta separates, the top of the womb is a little below the mother's navel. After the placenta separates, the top of the womb usually rises to the navel or a little above.
If 30 minutes have passed since the birth and there are no signs that the placenta has separated, be sure the baby has started to breastfeed. This causes contractions and helps push the placenta out. If the placenta does not come out after breastfeeding, have the mother urinate. A full bladder can slow the birth of the placenta. If the placenta still does not come out, see below
Help the mother push out the placenta
If the placenta does not come by itself after an hour, or if the mother is bleeding heavily, help her deliver it.
- Be sure the mother is already breastfeeding. If she is not bleeding too heavily, she should try to urinate.
- Put on clean gloves.
- Have the mother sit up or squat over a bowl. Ask her to push when she gets a contraction. She can also try to push between contractions. Usually the placenta slips out easily.
- The membranes (or bag) that held the waters and the baby should also come out. If some membranes are still inside the mother after the placenta comes out, hold the placenta in both hands. Turn it slowly and gently until the membranes are twisted. When twisted, they are less likely to tear inside. Then slowly and gently pull the membranes out.
- Feel the mother's womb. It should be the size of a grapefruit or a coconut, or smaller, and it should feel hard. See what to do if it is not small and hard.
Give oxytocin
If the mother cannot push the placenta out, or any time the mother is bleeding heavily before the placenta comes out, give oxytocin to help her womb contract. Before you give the medicine, gently feel the mother’s belly to be sure there is not a second baby in the womb. If you do not have oxytocin and the mother is bleeding heavily, do not wait, get medical help.
| To help the placenta come out |  |
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in the side of the thigh muscle | |||||
| (See how to safely give an injection.) | ||||||
| To stop bleeding from the womb after the placenta is out | |
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in the side of the thigh muscle | |||||
| or | ||||||
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by mouth OR in the rectum | |||||
| The woman should let the pills dissolve under her tongue for 30 minutes, and then swallow any remaining parts. If she is feeling nauseous, insert the pills into her rectum. Wear a glove. Note: To prevent deaths from heavy bleeding after birth, this medicine and the instructions above for how to use it can also be provided during the last months of pregnancy to women who will give birth at home. | ||||||
| or | ||||||
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in the side of the thigh muscle You can give this dose again in 15 minutes if bleeding does not stop, and then repeat the dose every 4 hours as needed. Do not give more than 5 doses of ergometrine (1.0 mg total).
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| To prevent infection if it will take more than 1 hour to get medical help |  | |||
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by mouth, 1 time only | |||
| and | ||||
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by mouth, 1 time only | |||
| You will need to give more antibiotics if the woman starts to show signs of infection. | ||||
When the womb comes out with the placenta
Rarely, the womb turns inside out and follows the placenta out of the mother's body. This can happen if someone pulls on the cord before the placenta has separated from the womb wall or if someone pushes on the womb to get the placenta out. It can also happen by itself — even if no one does anything wrong. An inside-out womb can bleed heavily, so work quickly but calmly.
What to do
- Scrub your hands and arms up to the elbows and put on sterile gloves.
- Quickly pour antiseptic solution (like povidone iodine, if you have it) over the womb.
- Gently but firmly put the womb back through the vagina and cervix into its normal position.If you cannot push it back up, you may have to roll it up with your fingers.
Push the part of the womb closest to the cervix in first, and work your way along to the top of the womb, pushing that part in last. Do not use too much force. This will be painful for the mother. Reassure her and have her breath deeply and try to stay relaxed.
If you cannot push the womb back into the right place, put it into the vagina and take the woman to a medical center. Treat her for shock.
- After the womb is back inside, rub it to make it hard. You may need to use 2-handed pressure to stop the bleeding. Give oxytocin, ergometrine, or misoprostol to stop the bleeding.
- The mother should lie on her back with a pillow, blankets, or other padding under her hips. Give her antibiotics to prevent infection.
After putting the womb back into the woman's body, get medical help.
Check the placenta and cord
Whether the placenta comes out by itself or you guide it out, you should check to see that it is all there.
Usually the placenta comes out whole, but sometimes a piece of it is left inside the womb. This can cause bleeding or infection later. To see if everything has come out, check the top and bottom of the placenta, and the membranes from the bag of waters. Also check the cord to see if it is whole.
Wear gloves when you check the placenta and membranes. This will protect you from germs in the mother's blood.
Top of the placenta
The top of the placenta (the side that was facing the baby) is smooth and shiny. The cord attaches on this side, and then spreads out into many deep-blue blood vessels that look like tree roots.
 extra piece |
 blood vessels go nowhere
There may be an extra piece inside the mother. |
Sometimes, but very rarely, there is an extra piece attached to the placenta. Check for blood vessels trailing off the edge of the placenta and going nowhere. This may mean that an extra piece is still inside the mother.
Membranes
You can see the membranes best on the top of the placenta. They will be broken open, but check to see if they are all there.
missing
Bottom of the placenta
The bottom of the placenta (the side that was attached to the womb wall) has many lumps. Sometimes the bottom of the placenta will have hard white spots or dark patches. This is not dangerous. To check this side, cup your hands and hold the placenta so that all the lumps fit together. Look for a hole or a rough edge where a piece might be missing. This piece may still be inside the mother.
Carefully look at every placenta after every birth just as you would carefully look at every baby. In this way, you will learn what they should look like and be able to quickly recognize when a piece is missing.
Cord
If you look carefully at the end of the cord, you should see 3 holes — 1 large hole and 2 small holes. These are the arteries and the vein (blood vessels) that carried the baby's blood to and from the placenta.
Some cords have only 2 vessels, and some babies with 2-vessel cords have problems later on. A doctor should check these babies.
A piece of placenta is left inside the womb
If a piece of the placenta or membranes is missing, it may still be in the womb.
Help the mother push the piece out by having the baby breastfeed or by massaging her nipples as if you were removing milk by hand. If the woman is bleeding, give oxytocin.
If the piece does not come out, get medical help.
If the woman is bleeding so heavily that she will probably die before getting help, try to take the pieces out of the womb yourself.
- Scrub and put on sterile gloves.
- Fold a piece of sterile gauze over your fingers. The womb is very slippery, and the gauze will help you scrape up small pieces of placenta. (Or tie a string to a strong piece of woven material like gauze, sterilize it, and keep it in your birth kit. The string will stay outside the mother so that you can easily pull the gauze out.) Be sure to use strong material that will not break apart and leave bits inside the mother's womb.
- Reach your gauze-covered fingers into the mother's womb and try to wipe out any pieces of placenta or membranes that are inside. This will be very painful for the mother. Make sure to explain what you are doing and why you are doing it — that any pieces of tissue left in the womb will make it impossible for her womb to contract and stop bleeding.
- After the pieces are removed, give antibiotics to prevent infection.
Even if you succeed in removing the piece of placenta from the womb, the mother still needs medical help. She may need a blood transfusion, and she is in danger of getting a serious infection. Take her to a medical center as soon as you can.
What to do with the placenta
Different people do different things with the placenta. Some burn it. Some dry it to use as medicine. Some just throw it away. For many people, burying the placenta is an important ritual. In some communities,
Burying the placenta is also a safe way to protect the community from the germs that live inside it. If you bury the placenta, make sure to dig a deep pit to keep animals from digging it up. If you do not want to bury the placenta, burning it is another safe way to dispose of it. See more information on protecting the community from germs that live in blood.
Watch for bleeding after the placenta is born
Womb stays soft
The most common reason a mother bleeds heavily after the birth is because the womb will not contract. Instead, the womb grows larger and feels soft after the placenta comes out.
The womb may stay soft because:
- the mother's bladder is full.
- there is a piece of placenta or membrane still inside the womb.
- the womb needs more oxytocin to make it contract.
- the womb needs more stimulation to make it contract.
- the womb is infected.
What to do
If the womb is soft, there are simple ways to make it firm:
Check the placenta again to see if there is a missing piece
A piece of placenta still in the womb can keep it from contracting completely.
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| Breastfeeding makes the womb contract and stop bleeding | |
Help the mother breastfeed
When the baby sucks, the mother's body makes its own oxytocin. Oxytocin makes the womb contract just as it did during labor. This helps slow the bleeding.
Help the mother urinate
When the mother urinates, her womb may be able to contract more easily. If she cannot urinate after 4 hours, she may need to have a catheter (tube) put into her bladder to help her urinate. See how to help a
woman urinate and instructions for using a catheter.
Rub the womb
See how to rub the womb. Teach the mother and her family how to check the womb and how to rub it to make it contract.
Give medicines
If rubbing the womb does not stop the bleeding, give the mother oxytocin, ergometrine, or misoprostol.
If you know of herbs or plants that stop bleeding and are safe, you can give those now. Do not put any herbs or plants in the vagina.
If bleeding continues
When bleeding does not stop and the mother’s condition worsens after you have used the methods above, try the following methods.
Give pressure inside the vagina
- Scrub your hands and put on sterile gloves.
- Explain to the mother what you are doing.
- Make your hand as small as possible and put it into the vagina. Move your hand to the back of the vagina, above the cervix, and make a fist. Do not put your hand in the womb. Move gently — your hand will hurt the mother.
- With your other hand, hold the womb from the outside. Move the womb down towards your fist, and squeeze the womb as you move it. The womb should begin to harden.
- When the womb feels hard, slowly let go of the top of the womb and take your other hand out of the vagina. Pull out any clots of blood in the vagina with your hand.
- If you know how, start an IV
Give pressure on the abdomen
- Wash your hands.
- Explain to the mother what you are doing.
- Position yourself above the mother and make your right hand into a fist. Place your fist just above and next to the mother’s bellybutton (navel), on the mother’s left side.
- With your left hand, find the pulse in the mother’s thigh.
- Straighten your right arm and push down hard on the mother’s abdomen with your right fist. This will compress the major blood vessel in this part of the body. Continue pressing hard on the abdomen until you no longer feel the mother’s pulse in her thigh.
- Keep pressing on the mother’s abdomen until the bleeding is controlled or until you get her to a medical center for care.
Use an anti-shock garment
An anti-shock garment is a rubber suit that squeezes the legs and lower body. If it is available, it may slow or stop the bleeding.
When to get more help
Watch the woman carefully until bleeding stops. If bleeding is not controlled by these methods, take her to a medical center right away. If she has any signs of shock, treat her for shock and take her to a medical center right away.
Torn vagina
If the mother is bleeding heavily and the womb is hard, she may be bleeding from a tear in her vagina. You may need to feel inside with a gloved hand to check for a tear. Learn about tears and how to sew them.
If you are not able to sew a tear that is bleeding heavily, try to slow the bleeding and get medical help immediately. Roll up 10 to 15 pieces of sterile gauze or another small, sterile cloth into a thick pad and push it firmly against the bleeding part of the tear. Hold it there until you get to a medical center.
Shock
When someone bleeds heavily she may go into shock. If a mother is bleeding, before or after the placenta comes out, watch for these signs:
- feeling faint, dizzy, weak, or confused
- pale skin and cold sweats
- fast pulse, over 100 beats a minute, that feels thin and faint
- dropping blood pressure
- fast breathing
- sometimes loss of consciousness
A woman in shock needs help fast. You must treat her for shock to save her life.
To help a woman in shock, get medical help. On the way:
- have the woman lie with her feet higher than her head, and her head turned to one side.
- keep her warm and calm.
- give her fluids. If she is conscious, she can drink water or rehydration drink. If she is not conscious, give her rectal fluids or an IV.
- if she is unconscious, do not give her anything by mouth — no medicines, drink, or food.
You may be able to get an anti-shock garment that uses pressure on the legs and lower body to help prevent shock in emergencies.