All midwives worry about postpartum hemorrhage. The three main keys to avoiding its occurrence are 1) good nutrition and supplements as needed; 2) knowing the mother; and 3) not rushing the delivery of the placenta. I have found that by applying these three keys as fully as I can both prenatally and in the third stage, my practice has a very low incidence of postpartum hemorrhage.
The first key to preventing postpartum hemorrhage is good prenatal nutrition and supplements. I always require that my mothers keep a five-day diet diary to give me early information about their diet. As soon as possible I recommend changes in their dietary habits if they are needed. I encourage them to use such supplements as 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. I have found the Spectrum 2C multivitamins by NF Formulas to be unsurpassed in their effectiveness for pregnant and lactating women. My families and I firmly believe in these vitamins, and many of them order from me long after the “big day.” I also use them to maintain my own energy level, as I am a busy midwife and the mother of two teen girls and a baby!
The second key, knowing the mom, entails making sure that you have recent blood work for this pregnancy. Check hemoglobin and hematocrit, of course, but also platelet count. You want to make sure the mother’s blood will clot properly after the placenta detaches. This key also includes knowing the mother’s nutritional status as discussed above.
The third key to preventing postpartum hemorrhage is to not rush the delivery of the placenta. Almost all postpartum hemorrhages, in my opinion, are caused by being in a hurry to deliver the placenta. In these cases, I believe hemorrhage is caused by the intervillous spaces not having a chance to contract and help control the flow of blood. Also, the overmanipulation of the uterus to facilitate placental delivery can 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. This is not any fun for the mother or the midwife! I have seen many physicians and a few midwives who will not give the placenta time to deliver on its own. I, too, have fallen victim to feeling a little harried as I waited for the placenta to come. But a policy of hands off, unless there is due cause, is the most important key to preventing postpartum hemorrhage. I have seen some bad postpartum bleeds, which may have been avoided if the practitioner had not intervened and over-managed the placenta delivery.
Uterine atony is also a major reason for postpartum hemorrhage. This 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. Try to anticipate this if she has had either of these labor patterns. Also, check and ascertain that she has not displaced her uterus by not emptying her bladder, either shortly before pushing and/or after delivery of the baby.
One of my favorite stories of postpartum hemorrhage concerns a mother who had all five of her babies at home. My proctor and future partner handled the first two. This mom’s uterus wouldn’t maintain its firmness after delivery no matter what was done. We resorted to the old trick of icing down small pieces of the placenta and giving them to her! The reasoning behind this “trick” is that the hormones from the placenta will be absorbed into the maternal bloodstream. Placing a small piece between the cheek and gumline causes the hormones to be transferred sublingually into the mother. This facilitates clamping of the uterus and helps staunch blood flow. Icing and rinsing the piece down is for the comfort of the mom and to remove the extra blood from the piece. (Animals eat their placentas after giving birth for this same reason; by disposing of as much afterbirth material as possible, they also help prevent predators from coming after them and their young.)
Giving the mother the iced placenta helped, but with her first birth she did end up at the emergency room the morning after the birth, where she was given Methergine to control the bleeding. The second birth was uneventful until after the delivery of the placenta. Once again, she bled quite a lot. We were able to control the bleeding better with this birth, but it was very worrisome to see that amount of blood. The third birth was about the same, with lots of blood, but we got the bleeding under control in a timely manner. I had served as her primary midwife with the last two babies, and because of her history of bleeding I started her on the above supplements. She didn’t, however, use the vitamins with the fourth baby. She dumped a bowl of blood with the placenta, but we got her under control very rapidly.
During her fifth pregnancy, she added the vitamins. My assistant caught the baby, and I took over for the third stage. Mom sat on the birthing stool. As I waited for the placenta, I silently reviewed what to do when she bleeds out. Everything was ready. Then came a small gush of blood, followed by the placenta. I thought so far so good, looks complete and delivers in a reasonable amount of time, but where is the huge gush of blood that is so typical of this mom? We got her off the stool, put a pad on her (tip: use a newborn diaper for the first couple of hours postpartum; it really helps control blood seepage onto the bed and/or clothes), and I continued to watch and wait for her to gush, but she never did. Her bleeding was very normal and never gave us any cause for concern. I can only attribute it to the supplements she took prenatally. She never had an episode of heavy bleeding and stopped completely about eight days postpartum.
- Midwifery Today Issue 48: Hemorrhage
- Midwifery Today Issue 34:Third/Fourth Stage
- Midwifery Today Issue 43