Hemorrhage is defined as estimated blood loss (EBL) greater than 500 mls (about 2 cups). This loss can may be a slow, prolonged bleeding that may go unnoticed by an untrained or inexperienced attendant or it may be a sudden gushing. Most (90 percent) of hemorrhages occur because the uterus does not clamp down and remains large, soft, boggy-feeling and flabby. When the uterus does not clamp down and restrict the blood flow, hemorrhage results. This is called uterine atony and is considered the most common cause of postpartum hemorrhage. Postpartum hemorrhage occurs in approximately 2-5 percent of vaginal deliveries and 6-7 percent of cesarean sections.
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. (Michael 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.
Hemorrhage can also be caused by a insufficient amount of vitamin K in the blood resulting in slow clotting at the placental site. Hemorrhage can also occur when the placenta partially detaches from the uterine wall, a precipitous delivery (very fast), an especially large baby or multiple babies (twins or triplets), tearing of the cervical or vaginal tissue. Hereditary abnormalities of blood clotting may cause hemorrhage as well.
Low hemoglobin in the blood is not considered a direct cause in postpartum hemorrhage, but it is a contributing factor as it increases the risk that hemorrhage may occur.
Uterine atony is a term used to describe the failure of the uterine muscle to contract normally following delivery of the baby and placenta. This condition is responsible for up to 90 percent of all cases of postpartum hemorrhage. Separation of the placenta from the wall of the uterus results in shearing of the mother's blood vessels that previously supplied blood to the placenta. Normally, bleeding from these severed vessels is stopped by contraction of the uterus and compression of the vessels. If uterine contraction is not adequate, bleeding can continue. At times, the uterus is prevented from contracting effectively by fragments of placenta that remain in the uterus after delivery or by benign growths of uterine muscle within the uterine wall known as fibroids. In these cases, the term "atony" usually is not applied. In most cases, the uterine muscle simply fails to contract adequately.
Women having babies too closely together without appropriate time between pregnancies for the body to recover, especially those with inadequate nutritional intake are also at higher risk for postpartum hemorrhage. It is important for women to wait 2-3 years between pregnancies when planning a large family to allow the body to recover from the stresses of pregnancy and birth while maintaining a nutritional diet with sufficient amounts of protein, calories, iron and other minerals and vitamins.
Hemorrhage may result if a piece or fragment of retained placenta and/or membranes remains in the uterus, thus preventing it from contracting down properly and constricting the open blood vessels. This can be a problem if the baby is postdates or the mother's diet is poor, resulting in an unhealthy appearing placenta that fragments or tears easily.
Massive hemorrhage is usually very obvious, but the slow seeping hemorrhage is the most dangerous as it can be overlooked during the excitement of a birth and the enjoyment of a newborn baby.
Risk factors for uterine atony include multiparity, multiple gestation, polyhydramnios, large infants, retained placenta, internal version and extraction, prolonged oxytocin induction, excessive magnesium use, beta-2 agents use for premature labor and chorioamnionitis. Uterine atony may present immediately after birth or hours later.
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.
Nutrition: 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.
Blood Work: 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.
The Placenta: 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. Over-manipulation 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 (fast) 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.
Hemorrhage prevention begins during pregnancy. Nettle or Alfalfa leaf infusion or tea taken throughout the pregnancy will increase the available vitamin K and hemoglobin needed in the blood.
MoonDragon has a pregnancy tea made of:
Peppermint is added for a minty taste and to help with digestion. Several cups of infusion consumed throughout the labor and postpartum will have less effect in preventing hemorrhage than taking throughout pregnancy, but is considered more of a preventive action. However I have used the pregnancy tea as a base for adding other herbs and tinctures during labor and postpartum.
Motherwort tincture is often used by midwives as a prevention for hemorrhage. The dose is 10 drops after the baby is delivered is claimed that it totally prevents hemorrhage. Motherwort is soothing and calming and a fine uterine tonic.
NORMAL MIDWIFERY CARE DURING THE FOURTH STAGE OF LABOR
Transfer the patient from the place of delivery once the placenta is delivered. This is usually a good time to have the mom take a relaxing and cleansing shower, with support by her partner and possibly another member of the support team at the birth. The soiled linens and bed pads or any other items are removed from the birth site. If she has given birth at another place besides the bed, have the bed made up ahead of time with fresh linens and bedding. If she has given birth in her bed, then these will need to be removed and replaced with all fresh bedding. Clean up and dispose of any mess and put dirty laundry in a bag for later cleaning.
After being cleaned up and redressed in a new comfortable nightgown or nightshirt, Assist the mom to her bed and get her comfortable with pillows. Make sure there are large protective pads placed under her to prevent leakage on the underlying sheet. A piece of plastic, such as a shower curtain liner can be helpful to protect the mattress from blood stains if placed beneath the bottom bed sheet.
Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from episiotomy especially if a tear has occurred and to reduce swelling from any manual manipulation of the perineum during labor from all the exams. Apply a clean perineal pad between the legs. I often recommend using incontinence pads instead of perineal pads since these cover more of the front and backside of the bottom for less leakage.
Once the mom is settled in with her new baby, obtain a complete set of vital signs, evaluate the fundal height and firmness, and evaluate the lochia. To ensure the fundus remains firm, preventing unwanted bleeding, externally massage the fundus until it feels about the size of a grapefruit with about the same firmness (feel a grapefruit through a pillow and it can feel very much like a clamped down uterine fundus). The nursing baby will help to keep the uterus firm by releasing natural oxytocin so it is important that the baby be nursing well and on demand (usually every few hours). The fundus should continue to be below the mother's umbilicus (bellybutton) and should remain firm at all times.
MASSAGING THE FUNDUS
Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour, and then, every hour for the next 4 to 6 hours or as needed. Be sure when the midwife leaves the home after the birth, someone is remaining with the mother for the next 24 hours that can be taught to do fundal massage as required and they are aware that when the massage is performed, occasional gushes and blood clots may be expelled.
Chart fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as two fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle, identify this and evaluate for distended bladder. Before the midwife leaves the home, be sure the mother has urinated at least once.
The person remaining with the new mother should inform the midwife if the fundus remains boggy after being massaged. NOTE: A boggy uterus many indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy (soft and mushy feeling) rather than firm feeling. This is descriptive of the postdelivery of the uterus.
MONITORING LOCHIA FLOW
Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the uterus. This may last for several weeks after birth. keep a pad count (save for the 24 hour visit by the midwife). Record the number of pads soaked with lochia during the first 12 to 24 hours.
Identify presence of bright red bleeding or blood clots. Lochia appears as a dark red or reddish-brown color. It looks totally different from hemorrhagic blood. Document thick, foul-smelling lochia. Observe for constant trickle of bright red lochia. This may indicate unnoticed lacerations. Identify lochia amounts as small, moderate, or heavy (large).
Document lochia flow when the fundus is massaged. (Every fifteen (15) minutes times one hour, then followed by every thirty (30) minutes times one hour, and every hour for the next 6 to 12 hours). Observe the mother for chills. The cause of the mother being chilled following birth is unknown. However, it refers primarily to the result of circulatory changes after delivery. The best means of relief is to cover the mother with a warm blanket.
MONITORING THE MOM'S VITAL SIGNS & GENERAL CONDITION
Take blood pressure, pulse and respirations every 15 minutes for an hour, then every 30 minutes for an hour, and then every hour as long as the patient is stable. Take the patient's temperature every hour.
Observe for uterine atony or hemorrhage.
Make sure the mom and her baby are comfortable and the baby is nursing properly before the midwife leaves the home (I usually stay a minimum of 2 to 4 hours after a birth to monitor the mom and baby). Allow the mom to get some well-earned rest.
Encourage the mom to continue drinking plenty of fluids, such as recommended herbal teas, juices, and broth and other nourishing liquids.
Observe mom's urinary bladder for distension. Be able to recognize the difference between a full bladder and a fundus.
A full urinary bladder is a spongy feeling mass between the fundus and the pubis. It can displace the uterus from the midline, usually to the right. There may be increased lochia flow. Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately.
Retained urine is less likely to occur at a home birth since we do not use labor medications and nerve blocks, which may prevent the mom from urinating. However, a long and hard labor can cause some swelling of tissues, which can cause some urinary difficulties. Frequent bathroom visits are absolutely necessary to keep the bladder empty. The mom may need assistance to the bathroom during the first 12 to 24 hours for support if she has problems with dizziness or being steady on her feet. Urine output less than 300cc on initial void after delivery may suggest urinary retention.
Document the fundal height and bladder status before the mom urinates. Re-evaluate and document the fundal height and bladder status after the mom urinates to accurately document an empty bladder.
MANAGEMENT OF POSTPARTUM HEMORRHAGE (PPH)
Uterine atony causes about 70-90 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. Be sure to 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 (not all midwives use or carry these drugs) for circumstances where a more definitive, heavy-handed approach is indicated. (Of course situations vary, requiring an individualized, dynamic response. For example, a few torrential hemorrhages I have managed responded well to immediate uterine compression followed by other interventions, which did not include pharmaceuticals, since I do not carry them.) Administration of oxygen (if you carry oxygen, considered another prescription medication) 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 (which is usually not used in a homebirth setting) 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/ml hour, 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.
The midwife may have the mother put the baby to the breast to nurse. This releases the natural oxytocin that the mother needs to help the uterus to contract. If the baby is not readily available or disinterested in eating, the woman's partner or another birth attendant may need to perform nipple stimulation. This can also be done using a breast pump. Angelica root tincture (50 drops) and Blue Cohosh tincture (20 drops), preferably homemade, every 2 to 5 minutes may be helpful.
The midwife should check to rule out uterine atony and express any clots that may have formed inside the uterus. Clots can prevent the uterus from contracting properly.
If the uterus is contracted, the midwife needs to assess for cervical, vaginal and perineal lacerations. Repairs need to be made quickly, either by the midwife or by transporting the mother to a her health care provider or hospital emergency room for extensive repairs.
If uterus is atonic:
1. The midwife should place the mother in an appropriate position to reduce hemorrhaging and to check the firmness of the uterus and do fundal massage of the uterus. If bleeding is occurring, the mother should be placed lying down on her back, knees down, legs together, feet elevated. The midwife should begin by massaging the uterus at about the umbilicus (belly button) semi-firmly in a circular motion, but not roughly or too lightly. This should stimulate the uterus to contract into a firm ball that is easily felt through the mother's abdomen (it feels like a firm grapefruit (size and firmness) would through a bed pillow). The bleeding should diminish.
2. Administer anti-hemorrhagic agents.
- Lady's Mantle tincture of fresh root is an excellent blood coagulant in a dose of 20-30 drops. Another hemostatic herb is Witch Hazel bark tincture with a dose of 20 drops under the tongue. These are often used before the placenta comes out, but can be used in combination with oxytocic herbs (listed below) for after the placenta has been expelled and when uterine atony is a cause. Repeat as needed.
- Oxytocic tinctures of Blue Cohosh, or Cannabis may be used in combination with hemostatic herbs (above) with a dose of 10 drops of oxytocic herb tincture and 20 drops of hemostatic herb tincture under the tongue. Repeat dosage as necessary.
- Shepherd's Purse herb is another blood coagulant and vasoconstrictor that works especially well with women. The tincture should be made of the fresh plant while in flower. It stops bleeding and promotes uterine contractions which is necessary for postpartum hemorrhaging problems. The dose of the fresh plant tincture is 20-40 drops under the tongue and is said to stop a hemorrhage in 5 to 30 seconds. If a dried plant tincture is used (as many of the commercial brands are made from dried plants), a dosage of 150 drops (1 teaspoonful) under the tongue should be used. Repeat every minute or as needed.
3. If hemorrhage is ongoing, perform bimanual compression.
Examine, or have examined, the placenta to ascertain if any fragments or cotyledons have been retained. If so, or if undeterminable, do uterine exploration.
Placenta, Fetal Side. Check for cord attachment and broken blood vessels along edge of placenta that could indicate an extra retained lobe(s). Placenta Exam, Fetal side. Placental membranes. Check for completeness. Retained membranes can contribute to hemorrhage problems. Placental membranes. Amnion & chorion layers. Maternal side of placenta. Check for completeness. Retained fragments can contribute to hemorrhage problems. Check for calcifications, blood clots, and other unusual signs of placental insufficiency or problems.
Placental abruption. Notice the large blood clot. Placental infarct. A calcification of the placenta contributing to placental insufficiency and possible fetal distress or demise. Placental succenturiate lobe (extra lobes running off of placenta, attached by blood vessels.
Monitor maternal blood pressure (BP) and pulse for signs of shock.
If bleeding not under control or mother not stable, transport.
The midwife or emergency response unit may start an IV.
If shock ensues, place mother in shock position, cover with warm blankets and administer oxygen.
For follow up postpartum care, advise complimentary therapies for anemia.
MoonDragon's Health & Wellness: Shock
USEFUL RELATED LINKS
Placental Triage: Indepth Description of Placenta Development & Function
MoonDragon's Birthing Guidelines: Retained Placenta
MoonDragon's ObGyn Pregnancy: Miscarriage
MoonDragon's ObGyn Pregnancy: Normal Labor - 3rd Stage (Delivery of the Placenta)
MoonDragon's ObGyn Pregnancy: Normal Labor - 4th Stage (Immediate Postpartum)
MoonDragon's Birthing Guidelines: Retained Placenta
MoonDragon's ObGyn Pregnancy: Placenta Previa
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