Postpartum Hemorrhage

One of the most difficult situations I encounter in my work is reassuring a mother that has had a postpartum hemorrhage that she can breastfeed. These women feel just awful and are often so discouraged because the facts they are dealing with don’t support my positive outlook. I am hoping to provide some encouragement to all pregnant women, so that they understand what a hemorrhage is, and on the off chance that they have one, feel confident that it can be overcome and they can still achieve their goals.

“A postpartum hemorrhage is defined as a cumulative blood loss greater than 1000 mL with signs and symptoms of a decreased volume of circulating blood in the body within 24 hours of the birth process, regardless of the route of delivery. While blood loss at the time of delivery is routinely underestimated, blood loss at the time of vaginal delivery greater than 500 mL should be considered abnormal, with the potential need for intervention.” While I don’t feel the need to address what occurs when the hemorrhage happens, I want women to understand how they will feel after it happens and they are home. These signs and symptoms vary, but most of my patients experience extreme fatigue and thirst, and are often very pale. Simple tasks are difficult (walking up stairs, showering) and actually caring for a baby and breastfeeding is daunting. Often the women I work with are going through heroic measures to breastfeed, usually at the expense of their health. I enter the home and find a frazzled family, trying their best to have the postpartum experience they dreamed of, while ready to give breastfeeding up, if they don’t collapse first. They are often very relieved when I address the situation and provide suggestions about how to make this happen while protecting Mom’s health as well. Here are my recommendations based on 30 years of experience and work with countless families in their homes after a hemorrhage. I realize that these recommendations contradict what women are often told at discharge regarding breastfeeding. But I promise that these suggestions will give you the best chance of achieving your goal to breastfeed your baby.

The first step to successful breastfeeding after a hemorrhage is acknowledging that you have been through a traumatic event that requires a change in your plan. If you have had a c-section as well, you need to remember that you have had a surgical procedure that comes with a 6-8 week recovery period. You simply will not be able to proceed as planned and will need to treat yourself with some grace and do only what is necessary. Your job is to heal, rest and bond with your baby. Anything that doesn’t need to be done by you, shouldn’t be done by you. Laundry, cooking, diaper changes, washing pump parts-these are all things that can be done by someone else. Limit visitors, unless they want to help you by performing those tasks. Anyone coming to your house should bring healthy meals or snacks, and limit their visit to a half an hour. They can stay longer only if they are willing to work. This is not a time for you to be entertaining. Your partner might have to be the gatekeeper and let visitors know that now is not a good time. Remember that people really do want to help. If they ask what they can do, be specific and tell them. Could you please come over and do my laundry? We need groceries, could you pick these items up? Can you take care of the baby for 3 hours this afternoon so my partner and I can sleep? Lastly, please remember the stress that hemorrhage at birth causes for your partner as well. Often they are forgotten about, as everyone is focused on you and the baby. About 2 weeks later, they melt down, usually from the heroic measures taken to care for you and the baby and lack of sleep. Make sure your partner is being taken care of as well.

The next step is getting comfortable with your baby having donor milk or formula. After a hemorrhage, your body is working very hard to produce new blood and replace what was lost. You are now asking it to produce two bodily fluids at once and your body is going to prioritize self preservation. As a result, you might be told that your baby is losing weight and needs supplementation. The bottom line is that your baby needs food, and giving him what he needs, will ultimately keep him happy and help you heal. To help facilitate this milk/blood production, you need to drink. A LOT. You will be thirsty, which will help to increase your intake, but you need to drink more than you think. A good practice is to chug an 8 oz glass of water before and after each feeding. Many women report that a combination of half Gatorade or Body Armour/half water makes a big difference in their hydration and how they feel. Do that every other feeding so you aren’t loading up on too much sugar. If you are running to the bathroom frequently, you are doing a good job!

Often women who have hemorrhaged are very swollen because of the amount of IV fluid/transfusions they have received. This can be very uncomfortable and make it harder to get around. Forcing fluids as noted above really helps. When you give your body the water it needs, it starts to release the water it is retaining. Laying down with your feet slightly elevated helps, as does walking around the house as tolerated. Make sure you get plenty of protein in your diet as well. Each snack/meal should have protein in it. Not only will it help your body heal and make new blood, it pulls the fluid out of your tissues and into your bloodstream so that you can pee it out.

Once you have focused on yourself and healing, you can start to focus on breastfeeding. In the hospital, they will have you feeding your baby every 2-3 hours. If you are physically capable of doing it, please do! Bring a nursing pillow to the hospital and use it to help support your arms. Have the nurses and LCs there to help you, and make an appointment while there to have one of us come to your home after discharge. I find that most women who have experienced a hemorrhage can do this, as you are running on adrenaline after the birth. It is often when you get home that everything hits you and the plan needs to change.

If they have you start pumping in the hospital, please do it according to their instructions. But remember, you are probably not going to get anything. It is expected and ok. Many women don’t know this, and it is completely crushing not to see any milk in the bottle. This starts a negative feedback loop, where you get nothing, it discourages you every time you do it, so then you don’t do it or do it less frequently. However, I want you to remember that even if nothing is coming out, the goal is frequent stimulation of the breasts, so that you will get milk eventually. Get excited even if you get just drops and know that those drops might not come for days! Please rent a hospital grade double electric pump-the Medela Symphony is the best one out there and the one most hospitals use. Often you can rent them directly from the hospital. We can bring one to you as well. In my experience, women who have hemorrhaged don’t see milk in the first week, which can be very frustrating. But if you know that this is normal given your delivery history, it is much easier to deal with and carry on.

Now, regarding a change in the plan once you get home. If everything is going well, keep doing what you are doing. If you feel as though you are about to collapse, you have to make adjustments. The first would be no nursing at night so that you can sleep. And possibly nursing every other feeding during the day. I know that this is breastfeeding blasphemy, but I really find it makes all the difference in your recovery. I am fine with you getting one 4-6 hour stretch of sleep. You would pump at the beginning and the end of the stretch, and nurse or pump every 2-3 hours afterward. When not nursing, you need to pump, on the highest suction that is comfortable for you, with massage. Limit pumping to 15 minutes. Longer is not better. Your body needs to be stimulated 8-10x daily to get your milk supply established, either by the baby or the pump. If you are doing that in a 24 hour period, it is fine to take that 4-6 hour break at night. Invest in a hands free pumping bra (I like the Rumina or the Kindred Bravely) to make life easier.

If you follow these instructions, you should see an increase in your milk supply after the first week (you might not get anything before then) and a full supply by a month postpartum. The important thing is to total up the amount of breast milk pumped each day, and to see that amount increase daily. You will always give that milk to the baby first if you have it. Then, as nursing is going well, you will see the amount of formula decrease. So the first goal is that the baby gets all breast milk, (either from breast or bottle) and then everything directly from the breast. Be patient, it will happen.

I have had the privilege to work with some amazing women in the past year who unfortunately experienced this scenario. Hopefully, they are reading this and acknowledging who they are and what they overcame! Two of them are nursing exclusively and I have no doubt will continue that for a year. Three of them worked with me to find a rhythm that worked for their family. This included nursing first at every feeding with formula afterward. Nursing just a couple of times daily, with formula bottles the rest of the time. Or nursing most of the time, with bottles of formula a few times daily. Either way, we came up with a plan that worked for them and they were able to enjoy breastfeeding because of it.

I am embarrassed to say that often I don’t get a chance to check my schedule before my day starts, so I don’t always know who I am seeing until they walk in the door. Imagine my surprise this July, when one of these patients walked in, 10 months after she delivered. Her birth had been harrowing and traumatic. She was nursing at most feedings, with formula bottles afterward. Now just nursing 3 times daily, she was preparing to go back to work as a teacher in the fall. She needed to wean before school started and came to see me for help with that. Her little girl was huge, and nursed happily throughout the appointment. I almost cried when I saw them, thinking of all they had been through, and how happy and healthy they both were! It was a good reminder that it can be done, you just need to have realistic expectations from the outset and take care of yourself. Please let us know if you need help with that!!!