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HEMORRHAGE DEFINITION
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%) 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.
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.
HEMORRHAGE CAUSES
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.
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.
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.
HEMORRHAGE PREVENTION
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:1 part Nettle Leaf
2 parts Raspberry Leaf
1 part Alfalfa Leaf
1 part Peppermint Leaf
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.
HEMORRHAGE REMEDIES
MANAGEMENT OF POSTPARTUM HEMORRHAGE (PPH)
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. 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
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