- Periodically spawns Fistuloids, and can have up to a maximum of 4 out at once. One Fistuloid will chase Isaac, while the rest will orbit the Matriarch.
- Spawns two small Fistula pieces once it takes 140 damage, and 2 more every 100 damage afterward.
- Spews a blood shot that leaves creep on the ground, like Mr. Fred. This shot can damage and bounce off of Fistuloids she has spawned.
- After taking 340 damage, the Matriarch will spawn a wave of glowing red Fistuloids that have 20 HP and rapidly lose health, making them shoot their maggots almost immediately. *After that, the Matriarch can use this attack just like any of her other attacks.
- When at low HP (after taking ~540 damage), The Matriarch will split into a medium-sized Fistula, 2 small Fistulas, a Fistuloid, and a low-health version of Chub, the latter being similar to how Brownie leaves a weakened Dangle upon death. Any Fistuloids that were orbiting the Matriarch will now orbit Chub.
- The Chub spawned from the Matriarch will always start charging in a random direction, regardless of Isaac's position before returning to the normal Chub pattern, similar to the Chargers spawned by Sloth.
- If the Chub that is spawned from the Matriarch eats a bomb, she will spit it back out at the player. Most bomb modifiers will still be on the bomb, with the exception of Bomber Boy.