May 25, 2005
Volume 7, Issue 11
Midwifery Today E-News
“Postpartum Blood Loss”
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Quote of the Week

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The Art of Midwifery

Measuring the amount of postpartum vaginal bleeding is best done by using a gram food scale and weighing the soiled pad. The weight of a clean pad is subtracted from the soiled pad's weight. One gram of blood is equal to one milliliter (mL). Any vaginal bleeding greater than 500 mL is considered hemorrhage and by medical standards necessitates placing that client from a low-risk status to a high-risk status.

Sandra Dederscheck, The Hemorrhage Handbook, a Midwifery Today book


ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

Research to Remember

A procedure to halt severe postpartum hemorrhage and provide an alternative to hysterectomy involves blocking the uterine artery. In a new procedure, a catheter is inserted through a small incision in the patient's groin, and a tiny balloon is inflated in the artery to immediately stop the bleeding. Microscopic plastic particles are then released through the catheter; they travel to the uterine artery to temporarily obstruct it. Embolization therapy alone has been shown in published research to be 80% effective; a Stanford study of 11 women underscores the effectiveness of adding balloon occlusion for further effectiveness. In the study, 9 avoided hysterectomy, 7 had balloon therapy followed by embolization, and 2 had only balloon therapy. Two of the women had a hysterectomy; they had not had balloons placed and their bleeding continued despite embolization.

Hysterectomy following postpartum hemorrhage is said to be the second-bloodiest procedure after cardiac surgery.

HealthLink, healthlink.mcw.edu


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Postpartum Blood Loss

Pregnancy is the only time in a person's natural life in which the blood flows out of the intact circulatory system. By full term the amount is impressive: 500-800 milliliters (mL) per minute, which is 10–15% of cardiac output. After childbirth, the size of the uterus shrinks rapidly; the active uterine muscle contracts and tightens itself, and the placenta is sheared off along a natural line of cleavage, the deciduas basalis. This is the point at which blood loss occurs. In the vast majority of births, this blood loss is minimal, and no harm occurs to mother or baby. Up to 500 mL of blood loss (about one pint) is considered normal.

The human body contains approximately four liters of blood. This amount varies substantially with the person's size. In pregnancy the blood volume increases, averaging six liters at full term. Most of this increase occurs during the second trimester of pregnancy, so the woman who is malnourished at this point (or chronically malnourished) is at a disadvantage when blood loss occurs.

To stop blood loss after placental delivery, assess the source. It could be coming from a laceration instead of the uterine blood vessels, necessitating repair. Is the uterus empty? Clots in the uterus can prevent firm contraction of the muscle, as can retained fragments of placenta or membranes. Blood loss is stopped by contraction of the uterus and by normal clotting of the blood in the placental site, which shrinks from the size of the intact placenta to just a few centimeters across as the empty uterus contracts. Shepherd's purse and red raspberry leaf are natural aids to this process. Angelica can help the uterus expel retained fragments.

Don't fall victim to the following all-too-common scenario: The placenta may or may not be delivered. A trickle of blood persists; the attendants can't get it to stop. They watch and wait. The blood pressure is good. She seems to be tolerating the blood loss. "She's a strong woman," they assure themselves.

But the body has many mechanisms to protect itself from shock. The pulse is actually a more sensitive indicator of impending danger than blood pressure, and a steadily rising pulse rate may warn us that it is time to act. If blood loss persists, the mechanisms will fail, and the woman will rapidly go into shock.

An emergency transfer occurs. In the hospital, the woman's condition is found to be so critical that blood transfusion must be given before she is stable enough to undergo procedures to stop her hemorrhaging. Even getting intravenous access is difficult when shock has occurred. Also, if the placenta is still in, she faces additional blood loss with placental delivery. Don't put a woman into the dangerous position of already being seriously depleted of blood with the placenta still inside! Learn to assess blood loss and observe for it critically at every birth.

Marion Toepke McLean, excerpted from "Unchanging Protocols," Midwifery Today Issue 73

TO LEARN MORE ABOUT HOW TO ASSESS BLOOD LOSS, order Midwifery Today Issue 73 to read the remainder of this article. Go here.


Hemorrhage before the complete birth of the placenta can be very severe and happen without much warning. In this case the uterus is still supplying the placental bed as if it were supporting the life of a term fetus, with the normal 500 cc per minute of blood flow. The uterus, however, has released the baby, but because of the lack of placental detachment, it is failing to contract as it should under this circumstance. The uterine wound of the detached area will be pouring out blood. You must act quickly in this event. Resist the temptation to pull too hard on the cord as a way to extract the placenta. Some cords are quite fragile and can tear off, leaving you in a much more difficult position.

If the mother is slim enough and there is not an abnormally attached placental area, you may be able to get this placenta to detach by an action that resembles squeezing a cherry to pop out the pit. Both hands are placed on either side of the uterus (not on the fundus) and begin compressing toward each other. Stand to the mother's side and work with strong steady pressure, slightly lifting the uterus up (toward her chest) while compressing, which will often in itself help the uterus contract and expel the placenta. The pressures of the hands works toward one another, with greater proximity at the top of the uterus than the bottom; in other words, press the mass of the placenta toward the cervix, slightly. Before you begin, explain to the mother what is happening, what you are about to do, and why. The cherry-pit technique seems to work in greater than 60 percent of these cases. If it doesn't and bleeding is brisk, you cannot dally. You must go in after the placenta because 500 mL/minute (or more) loss can deplete the mother within moments. If her condition is weakened and there is time, try to get something nourishing in her to boost her strength. I like to use Vegex vegetable bouillon; I have seen women with no color in their faces pink up when they take the first few sips. Miso broth is also excellent, better still if it has seaweed in it. Giving oxygen to the mother by mask can help increase the oxygenation of her plasma; this appears to give strength to her muscle tone as well as improve her status in general.…

One postpartum trick I learned is to "blot and count." That means when you are observing the mother's vaginal bleeding after the placenta is out, you blot the stream and count how many seconds pass until it starts to bleed again. It should be three seconds or longer. Anything sooner than this is too much bleeding. It often is those subtle trickles of bleeding that are the most dangerous. Women have been known to slowly bleed to death in their sleep, especially if given pain or sleeping medicine. The rapid gushers are obvious; the insidious trickles are not. I have read that death from a postpartum hemorrhage occurs an average of five hours after the birth.

Another lesson on hemorrhage is how to properly massage a uterus. Everyone has been trained to "massage the fundus," but it is rarely the fundus that bleeds! Obstetrical or midwifery textbooks contain illustrations of how the uterus pulls up on itself in labor. The fundus becomes very much more thickened than the walls, which then taper down, getting thinner toward the cervix. So unless the placental implantation site is entirely in the fundus, the bleeding site will be where the placenta was, on the thinner side walls. This area has far less endometrial fibrous tissue with which to contract down upon the vessels that supplied all that blood to the placenta. So it is not the fundus that needs all the attention! Massaging the fundus also creates more pain than focusing on the side walls, may actually damage some of the supporting structures of the woman's uterus, could push the fundus down into the uterine cavity if there is very low tone (causing an inversion and/or prolapse) and could delay what you needed to do in the first place: get it into firm tone. Massage the sides of the uterus! If you also lift up just slightly on the uterus this will elicit a response from the stretch receptors, and the uterus itself will help you. You can feel this happening under your hand. The only value to ever touching the fundus is to evaluate how elevated it is in the pelvis as a landmark. The massage should be firm but gentle—you don't want to create pain.

Lisa Goldstein, gleaned from "Some Thoughts on Postpartum Hemorrhage," The Hemorrhage Handbook, a Midwifery Today book


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Forum Talk

I have been shown to have APA (antiphospholipid antibodies) and I am now on Lovenox and one baby aspirin a day. I am also on progesterone and biweekly HCG and progesterone testing. My last miscarriage was in February at 13 weeks and was emotionally hard to handle, so I am OK with the precautions we are taking now. Does anyone have ideas about how to "handle" Lovenox or other blood thinners with a homebirth (I don't know if I'll be changing meds at any point or going off them altogether).… Is there any information out there about the risks involved in going off the meds close to birth? Does it lead to immediate clotting?

Prov


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Remember that you are writing to a conservative medical board and so choose your words wisely. For example, if we met via the freebirth community, just say "childbirth" instead. Please show me your letter before you send it. Send it to me priority mail or by e-mail. Send a copy of your letter to Jeannine Parvati Baker, 10 N. State St., Joseph UT 84739 or e-mail it to jpb@birthkeeper.com. Once you hear back from me, please send the letter directly to the name and address below:

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Question of the Week (Repeated)

Q: A client has a degenerative kidney disease called IgA nephropathy. She is showing +1 to +2 protein in her urine, her average blood pressure (BP) is 130/82. She is seeing a nephrologist and getting her labs done monthly: sodium, potassium, chloride, carbon dioxide, calcium, glucose, phosphorus, BUN and creatine, albumin—all of which are in a normal range. I am looking into alternative methods for supporting and nourishing her kidneys through the pregnancy. She has seen an acupuncturist (per my suggestion) one time to receive treatment and herbal supplements. She is 20 weeks pregnant. In addition, we helped her with a homebirth 2-1/2 years ago, and during that pregnancy she had no protein that spilled in her urine and her BP was more like 110/66. Do readers have recommendations and/or experience?

— SC


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: Recently, as an L&D nurse, I ended up delivering a double-footling breech baby. I received some criticism from another nurse that I should have let the baby's head remain in the vaginal vault. She states that it is OK to leave such a presentation for up to an hour. The OB who came in later said, You have four minutes to get the baby delivered. Who is correct? I entered into this delivery at change of shift, and patient was in triage area awaiting a surgeon for c-section. I was presented with two feet and buttocks out of the perineum.

— Gretchen Jenkins

A: Always make sure baby is not distressed by checking heart rate. If all is fine, it is appropriate to leave baby to birth in its own natural time. You would of course need to check for prolapsed cord. I guess in hindsight you would be asking the obstetrician the reason for the decision that baby needed to be out in four minutes. Was this because of trauma, was it standard hospital procedure, or was it his/her own fears coming into play?

The main issue is that the mother and baby are in good health physically and emotionally from their birth experiences, and that you yourself know in your heart that you did what you believed to be right at the time for the situation you were presented with.

— Shelley

A: The obstetrician was correct. Once the head moves down into the birth canal, the cord, which is going up beside the head, is flattened and the baby is no longer receiving adequate oxygen supply. Congratulations on a successful delivery!

— Judy, CPM


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Feedback

How do nurses figure out when a new week of pregnancy starts? For example, if a patient is 35.6 weeks pregnant, is the next day considered 36.7 or 37 weeks pregnant? How is the exact number of weeks and days figured out when a patient is first admitted?

I have a pregnancy wheel but I don't understand how you determine the exact number of weeks and days pregnant someone is. I am a med/surg nurse and am very new to ob/gyn. I notice the nurses giving other nurses exact weeks and days pregnant but just don't understand how to calculate and keep track of weeks and days. Can readers please explain it to me?

Marianne

For more than 20 years, the nonprofit organization Population Communications International (PCI) has been assisting local talent develop educational and entertaining radio programming. PCI-assisted programs have won international awards for excellence and have become the most popular radio programs in numerous countries.

In 2005, PCI is offering workshops in Guatemala, Mexico and Peru to those who are interested in learning more about the field of entertainment education (EE) and how to produce effective radio programs, including radio serial dramas. Those who successfully finish the workshop will then also be eligible to submit proposals for a seed grant to produce and air their own radio programs.

This is an opportunity for midwifery organizations in Mexico and in Latin America to learn how to educate and promote their cause through the use of mass media. Do not miss out on this opportunity! The first workshop is taking place in Guatemala at the end of May. Get your application in now! Scholarships are available to cover tuition costs for the four-day workshop, room and board.

For more information in Spanish and to download your application please look at: www.population.org/taller

Spanish and non-Spanish speakers can also call PCI headquarters in New York City and ask to speak with Natalia or Nadine at International Programs. The phone number is (212) 687-3366.

Nadine, Mexico


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