August 27, 1999
Volume 1, Issue 35
Midwifery Today E-News
“Postpartum Hemorrhage”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Avoiding Postpartum Hemorrhage
5) Management of Postpartum Hemorrhage
6) Question of the Week
7) Question of the Week Responses
8) Switchboard
9) Coming E-News Themes

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1) Quote of the Week:

"The doctor of the future will give no medicine, but will interest his patient in the care of the human frame, in diet and in the cause and prevention of disease."

- Thomas Edison

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2) The Art of Midwifery

If the birthing woman is cold, it will increase the levels of catecholamines. The concentration of catecholamines affects the risk of postpartum hemorrhage.

Some experienced midwives also find it plausible that undisturbed eye-to-eye and skin-to-skin contact between mother and baby during the hour following birth influences the maternal hormonal balance and the release of oxytocin.

- Michel Odent, MD

While observing vaginal bleeding after the placenta is out, blot the stream and count how many seconds pass until it starts to bleed again. It should be three seconds or longer. Anything sooner is too much bleeding. This is a useful indicator especially with trickle bleeding, which can be the most dangerous.

- John Carpenter, MD via Lisa Goldstein, CPM, CNM

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3) News Flashes

Breastmilk produced by the mother of a preterm infant differs in composition from that of a mother who has delivered at term. Specifically, preterm milk has significantly higher concentrations of lipids, protein, sodium, calcium and selected immunoglobulins. The low osmolarity of human milk and the presence of immunoglobulins are thought to help an immature gastro-intestinal tract adapt to enteral nutrition.

Preterm infants have a reduced ability to utilize dietary lipids due to a reduction in pancreatic lipases. The enzymes in human milk help improve the efficiency of fat breakdown, leading to better absorption.

- The Practising Midwife, 2(7), July/Aug. 1999

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4) Avoiding Postpartum Hemorrhage

The three main keys to avoiding postpartum hemorrhage are good nutrition and supplements as needed, knowing the mother, and not rushing the delivery of the placenta. I always require that mothers keep a five-day diet diary. As soon as possible I recommend changes in their dietary habits if they are needed. I encourage the use of liquid chlorophyll, red raspberry and nettles. I also make a tincture of nettles, yellowdock, alfalfa and red raspberry, which I have on hand if it is needed.

The second key, knowing the mom, means making sure I have recent blood work for this pregnancy. I check hemoglobin and hematocrit and platelet count. I want to know if the mother's blood will clot properly after the placenta detaches.

As to not rushing the placenta, almost all postpartum hemorrhages are caused by being in a hurry to delivery the placenta. I believe hemorrhage is caused by the intervillous spaces not having a chance to contract and help control the flow of blood. Overmanipulation of the uterus can also cause lobes to be left on the uterine wall which result in uneven contraction of the uterus. These lobes need to be manually removed to prevent postpartum hemorrhage and infection.

Uterine atony is also a major reason for postpartum hemorrhage. It can be caused from a long labor or a precipitous labor, either of which can induce uterine fatigue and facilitate possible partial separation of the placenta. I also ascertain whether the mom has not displaced her uterus by not emptying her bladder, either shortly before pushing an/or after delivery of the baby.

- Margaret Scott, CPM in Midwifery Today Issue 49

====

5) Management of Postpartum Hemorrhage

Uterine atony causes about 70 percent of PPHs. This condition is usually very responsive to non-pharmacologic measures, and these may be tried first. I generally start with fundal massage and nipple stimulation, uterine re-positioning, then abdominal aortic compression, and finally bimanual compression. I consider whether the woman has emptied her bladder recently and is otherwise comfortable. If the uterus remains soft but bleeding is being controlled, herbal therapies like blue cohosh or motherwort may be considered, reserving oxytocic drugs for circumstances where a more definitive, heavy-handed approach is indicated. (Of course situations vary, requiring an individualized, dynamic response. For example, torrential hemorrhages I have managed responded well to immediate aortic compression followed by other interventions, which did not usually include pharmaceuticals.) Administration of oxygen at 4-5 liters/min. should begin with any signs of shock and/or blood pressure at or below 70/50. Emergency response measures should be initiated; steps taken to assure fluid resuscitation; and core-perfusion maintained via lower extremity elevation, and in some cases, anti-shock compression pants or wrap.

Should pharmaceutical oxytocics be indicated, the American Academy of Family Physicians recommends the following protocol: up to 40 units of oxytocin (Pitocin) in a liter of normal saline, administered at a rate of 250/mlhour, or 10-20 units IM. Oxytocin acts to rhythmically contract the upper uterine segment. (Direct, undiluted IV injection of oxytocin is to be avoided, as it increases hypotension, exacerbating perfusion problems associated with hemorrhage.) If the response to oxytocin is inadequate after several minutes and the woman is not hypertensive or toxemic, give ergonovine (Methergine) 0.2 mg IM. This agent acts on both upper and lower uterine segments, causing tetanic contraction and vasoconstriction. Note that ergot administration commonly causes transient hypertension, nausea or vomiting, dizziness, headache, palpitations, chest pain, or shortness of breath. Since many of these side effects are synonymous with symptoms of shock, special care should be taken to determine if adequate treatment response is occurring. Onset of action is two to five minutes.

Some practices have access to Prostaglandin F2 15-methyl (Hemabate), which may be administered IM or intramyometrially (injected directly into the uterus through the abdominal wall). Dosage is 0.25 to 1.0 mg, repeated up to a total of 2 mg. Onset of action is five minutes.

All the while the practitioner should be actively assessing the root cause of the bleeding, whether the treatments are working, and planning for the next step.

- Judy Edmunds, CPM, in Midwifery Today Issue 48

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6) Question of the Week: Here in Mexico it is big business to be able to turn a breech baby anywhere between 3-6 months. I wonder about the risks involved and if anyone out there finds this a successful procedure?

- Evette, aspiring midwife

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7) Question of the Week Responses

Q: What steps do you take in your practice to avoid postpartum hemorrhage (PPH)?

Don't cause it! (hands off during third stage). Get baby to breast soon. Have mom push out the placenta, no pulling.

This may sound silly but I often "talk to" the placenta, thanking "Madame Placenta" for its wonderful function and now, would you please come out? I think this calms me down (if it's a long third stage) and it calms the family and adds a little humor to an otherwise tense situation.

If the woman has a history of PPH, I will often offer her shepherd's purse tincture prophylactically, two droppers full under the tongue after the placenta delivers. Have her hold it under the tongue as long as she can stand it, then follow with a little bit of water to drink.

Massage the uterus and be very aggressive if you have to. Having worked over ten years in a hospital practice prior to doing home/birth center births, I learned to be very aggressive in this. I just put it down as a life saving measure and don't sweat not being nice.

Be aggressive with Pitocin followed by Methergine if the above doesn't help. The above measures have really worked well for me, and I very very rarely have PPHs.

- Annette Manant, CNM harmonyu@telisphere.com

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As long as there is no (or very slight) bleeding, I wait for signs of placental separation. Sometimes if I need to stitch I go ahead with this, or just sit and admire the baby When the placenta has separated, I put a hand on the fundus to clue the mother in to when she has a contraction, and get her to push the placenta out. I do not find the test of placental separation where you push up the uterus and see whether or not the cord pulls up to be accurate. What this tells you is whether or not the placenta is through the cervix. If the placenta is separated but not through the cervix, I may assist the mother's pushes with controlled cord traction in the curve of carus.

I am more active if there is a lot of bleeding. After the placenta is delivered I make sure there are no clots in the uterus, then try to promote quiet time with privacy for mother and baby to tune into each other and get the baby onto the breast. The human body has natural mechanisms to stop the normal bleeding which goes along with childbirth before it becomes a hemorrhage, and I try to work along with these natural systems. However, I don't hesitate to use other, more interventive techniques if hemorrhaging begins. Too much blood can be lost very quickly.

- Marion Toepke McLean, CNM

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8) Switchboard

In reply to the question about the risks of continuing to nurse through a pregnancy when the client has a history of preterm labor [Issue 32]: First, feed the mother. We midwives have all helped a lot of pregnant women who were nursing their babies. I'm sure mothers have been doing this for thousands of years. I like to always go back to the thought, "What did they do 300 years ago?" That will always get us closer to how this process was designed than anything we see today.

- Jan Tritten

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I delivered a baby at about 5 1/2 months. Because of this, I've been considered a high-risk patient. Later I birthed a full-term baby and breastfed her. When she was 14 months old I discovered I was pregnant again. I continued nursing her. This new baby's placenta began to detach, so I was ordered on bedrest but not to stop nursing. After 3 weeks, everything was back to normal. I carried this baby 2 weeks past his due date and delivered a perfectly healthy and normal 12 1/2 lb baby (vaginally, side-lying and no tearing, by the way).

- Julia Goforth

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About nursing while pregnant, read: Breastfeeding during pregnancy. SR Moscone, MJ Moore. Journal of Human Lactation 1993; 9(2): 83-88. Tandem nursing--before and after. V Nichols-Johnson. ABM News and Views 1996; 2(1) : 6-7.

- Francoise Railhet
Manager, LLL France Medical Associates Program

====

It is my understanding that, although stimulation of the breast does produce oxytocin (for milk letdown) that contractions will only happen if the receptors for that hormone are present in the pregnant woman's body. The presence of oxytocin receptors peaks near the end of pregnancy as part of the dance of the beautifully intricate endocrine system pregnant women have. Perhaps your client's oxytocin receptors peak early in pregnancy; however, she may have other factors (nutrition, weight, smoking, stress) that predisposed her to preterm labour. I know many women (including myself) who have nursed a toddler through their pregnancies, with no preterm labour Unfortunately, I know of no studies on this subject, but myths abound.

- Trudy Noort

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In response to the request for comments on PKU in Issue 33: PKU was first identified here in Norway, and we have one of the highest incidences in the world of this inborn error of metabolism, along with an excellent follow-up system. The test we use for it checks for the presence of phenylketones in the blood, which only appear in measurable amounts after the baby has been receiving milk feeds in such amounts as to exceed the affected individual's ability to process the amino acid phenylalanine. We have a screening program with virtually 100% coverage, and babies are screened once, as close to 72 hours of age as possible. The blood sample is also used to check for hypothyroidism, which is apparent at birth. To avoid having to take two blood samples of each infant, our national health authorities have landed on three days as a good compromise-- ate enough so the PKU test is reliable, and early enough that the hypothyroid babies are not jeopardized by a delay in testing. I don't have the references for this protocol, but this is one aspect of our health service which really works well.

- Rachel Myr, midwife

====

In answer to a query about taking Zoloft (sertraline) whilst breastfeeding [Issue 32], I can confirm that it is safer than Prozac. The transfer for of sertraline and its metabolite is minimal and will almost be undetectable unless you are taking much more than 150 mg per day. If you have to go back to using Prozac, don't worry; it has been shown that your baby will receive only 5-9% of the maternal dose, the peak being within 6 hours. Colic, fussiness and crying are side effects, but these have only been reported in one baby, the others showing no short-term problems.
(Ref: Medications and Mother's Milk. 1998-1999. Thomas Hale, Ph.D. Pharmasoft Medical Publishing, US)

- Marianne Idle (Midwife)

PS. I have had no replies to my query about the safety of castor oil to induce labour. Does this mean that all you midwives who are using it are absolutely sure it is safe? Have any studies been done? What about hypertonic contractions?

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What causes a collapsed and inverted uterus? I have a friend who nearly died with this problem. She can't find any information on it.

- Giselle Whitwell, prenatalmusic@yahoo.com

The doctor probably pulled out the placenta before it was detached. This problem is almost always iatrogenic (doctor caused). With normal physiological third stage this condition is very rare.

- Jan Tritten

====

[Re: preterm labor, Issue 32]:I was taught that ovulation normally occurs 14 days before the beginning of the next menses, regardless of cycle length, so for a 21-day cycle, ovulation occurs on day 7 and for a 41-day cycle, ovulation occurs on day 27.

When women have unusual cycle lengths, I always calculate the due date from the estimated ovulation (conception) date, not the date of the last menses. Then I calculate the gestational age through the pregnancy from the EDB, not the LMP. Still, there are ladies who make healthy babies "fast" and "slow," so the problem isn't entirely solved, but this certainly helps!

- Cynthia Flynn, CNM, PhD

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I am a direct-entry CNM in New York City. I went to nursing school to become a midwife before our law was changed and I never practiced as a nurse in any way. I have been a doula since 1994. I finished my training last year. I have been looking for a hospital job since November 1998 thinking that after a year or two, I'd have "enough" experience to attend homebirths. Meanwhile, numerous people have asked me to attend them at home and no one has offered me a hospital job. I've talked to several homebirth midwives in our area who have said I don't need to work in a hospital. A midwife I know is willing to attend my births and take me to hers until I feel ready to solo. Are there others out there who did the CNM route but started off in homebirth who might have wise words for me?

- BC

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I am 38 years old and never been pregnant. My gynecologist has told me I have a tilted uterus. Would this interfere with getting pregnant? Would certain positions help the sperm get to the egg any better than others? I have read that the best time to get pregnant is from days 12-15 after your period and you should have sex every day on those days. I also read that sex every other day is better. How do you know for sure if you're ovulating and the best days to have sex? I don't have thousands of dollars to spend trying to get pregnant. Is there some kind of basic, simple test that might even let me know if I could get pregnant or not, and if so, what would it
cost?

- Jean

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Share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com

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9) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- Herpes (Sept. 3)
- Circumcision (Sept. 10)
- Preeclampsia (Sept. 17)
- Breastfeeding (Sept. 24)
- Vitamin K (Oct. 1)

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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