Three Keys to Avoiding Postpartum Hemorrhage
by Margarett Scott, CPM
© 1998 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in
Midwifery Today Issue 48, Winter 1998. Reprinted in The Hemorrhage Handbook.]
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.
Margarett Scott is a certified professional midwife with a thriving
practice in Oklahoma. She has been practicing for more than eleven years and specializes
in waterbirths, VBACs and primips. She currently shares office space with her backup
physician, whom she highly appreciates for his professionalism and respect toward
her and her families. She homeschools her two teen-age daughters and is the mother
of a baby boy.
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