Some studies looking at factors associated with excessive postpartum bleeding find an association with epidural analgesia while others do not and still others don't evaluate it as a factor. The most likely explanation for an association is that epidurals increase the use of oxytocin and instrumental vaginal delivery, both of which increase risk of excessive blood loss. This is because instrumental vaginal delivery increases the likelihood of genital trauma, and high doses of oxytocin, especially over long periods, provokes oxytocin receptors in the uterine muscle to shut down, thereby decreasing muscle sensitivity to oxytocin. (This is undoubtedly a mechanism intended to protect the fetus from overly long, overly strong contractions.) 

~ Henci 

Could it also be a problem for epidural bleeding that the uterus sometimes lags behind with the epidural?

To start with, using scare tactics instead of providing information is a huge red flag that should send your client heading for the door, but you probably already knew that. (And that, Ladies and Gents, is a major reason why I stopped being a doula and a Lamaze teacher and concentrated on writing and speaking. I couldn't take watching women lie down on the railroad tracks, much less witness helplessly the train roll over them, any more. I have enormous admiration for all of you able to stick it out in the trenches.) There is a new Cochrane review of 3rd stage management coming out soon, although I don't know when. I had the privilege of acting as a "consumer reviewer" on a draft. I have not seen the final version, but the draft I reviewed takes a much more nuanced view of the potential benefits and harms of active management of 3rd stage than the prior version. That's not going to help you right now, though. As for using Cytotec, there is a Cochrane review on that. The tweet version is that if you are routinely going to give a drug to contract the uterus, injecting oxytocin is preferable because it has fewer unpleasant side effects and does a better job of preventing severe hemorrhage.  

-- Henci 

Thank you for addressing this, Henci -

I came here hoping to find your thoughts after a client's OB told her that not administering Pitocin for third stage is like to "performing a C section and leaving the incision open, without closing it up with stitches." I had already shared Dr. Sarah Buckley's article on third stage, as well as some very recent research showing a possible link between third-stage Pitocin and breastfeeding challenges. The Cochrane review on Pitocin in third stage seems to be down right now? It says the review has been withdrawn.

I would be grateful for your thoughts on routine oral misoprostol in third-stage. That is most common here in my region, but I have not seen any research indicating harm when used in this way (after delivery). "Here, take this little pill" is usually what happens, with a nurse's hand and a cup of water shoved in mom's face after birth, with no explanation of what they're giving here (which is why I work so hard to prepare my couples for what to expect). I've been presenting it as a philosophical issue of "potential/unknown risk of an intervention" when discussing with my students and clients, but would love to know if there is research on Cytotec postpartum, as you indicated it is potentially more harmful than Pitocin.

Thanks for all you do for moms and babies!

Your timing is superb. I just finished writing the chapter on active management of third stage labor for the new edition of Obstetric Myths Versus Research Realities.

So here's the deal: Random assignment trials show that routine administration of oxytocin after birth reduces postpartum blood loss compared with using it only to treat excessive bleeding. But -- you knew there would be a "but" -- clinically important differences are trivial. Trials conclude that routine oxytocin reduces postpartum hemorrhage, which sounds alarming until you learn that hemorrhage after vaginal birth is defined as estimated blood loss of at least 500 ml -- that's a pint. That, in fact, is the amount of blood they take when you donate blood, and that's without considering that pregnant women have considerably expanded their blood supply in the last trimester to meet the needs of their growing baby and to cushion against blood loss at birth. According to William's Obstetrics, the obstetric bible, healthy postpartum women don't begin to show actual symptoms of excessive blood loss until they have lost around 1500 ml. And, yes, while studies also find small differences for greater amounts of blood loss that favor routine use of oxytocin, trials also show that when oxytocin is reserved to treat excessive bleeding, women are not more likely to have another heavy bleed after 24 hrs and before 6 wks, require hospital readmission, or experience excessive fatigue.

Meanwhile, if the goal is keeping blood loss within physiologic range--remember, this isn't a case of "the less the better;" women are supposed to get rid of their excess blood supply as part of normal postpartum involution -- there are a number of hugely overused labor procedures that increase blood loss. Starting with the obvious, you have episiotomy. One study of mediolateral (the cut goes toward one side of the anus) episiotomy, the type done in most countries other than the U.S. and Canada, reported that having a mediolateral episiotomy increased blood loss by the same amount as giving routine oxytocin reduced it.  In other words, you could do just as well simply by not having an episiotomy as by routinely injecting oxytocin after the birth. Another obvious cause is instrumental vaginal delivery. A not so obvious cause is oxytocin induction to start labor or augmentation to strengthen labor. Why? With long periods on high doses of oxytocin, the uterine muscle begins to lose sensitivity to oxytocin, which means it doesn't clamp down as well after the birth. Finally, epidurals are associated with increased incidence of excessive bleeding not in their own right but because they increase use of instrumental vaginal delivery, episiotomy, and oxytocin.

You would not be unreasonable if you refused routine use of oxytocin. You would be well advised to avoid if possible procedures that increase risk of excess postpartum blood loss and to flat out refuse episiotomy. Those “avoid if possible” procedures include cesarean surgery, of course. (Curiously, blood loss associated with cesarean section isn’t called a “hemorrhage” until 1000 ml, double the amount after vaginal birth.) This strategy will minimize your risk of excessive bleeding without introducing the risk of adverse effects, something that cannot be said of routine oxytocin. Oxytocin isn’t as bad as the other medications (ergot compounds, misoprostol) that may be administered routinely to prevent bleeding, but it will increase cramps, which can make the early postpartum more unpleasant and interfere with bonding and breastfeeding. And there you have it.

-- Henci

P.S. While you are at it, you want to birth the placenta by your own efforts, not by the care provider pulling on the umbilical cord (umbilical cord traction), and you do not, repeat do not, want to permit the umbilical cord to be clamped until it stops pulsing or the placenta detaches. Early clamping deprives the baby of a substantial portion of its blood supply. Draining the baby's blood back into the baby helps the placenta detach more easily as well.