November 14, 2001
Volume 3, Issue 46
Midwifery Today E-News
“Hemorrhage”
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THIS WEEK'S ISSUE

Contents:

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Quote of the Week:

"Birth is an adventure--let's make it a good one."

- Lisa Hines, licensed midwife


The Art of Midwifery

Women who bleed excessively need special attention after birth. Fluid replacement, good nutrition, and extra help at home are essential to a good recovery. A mother has already drawn upon her body's iron stores in growing her baby and the extra blood supply of pregnancy. Even when her hemoglobin and hematocrit return to normal, keep her on a super-nutritional diet for several months so she can replenish the iron and other minerals that the body stores in the bone marrow.

- Marion Toepke McLean, Midwifery Today Issue 48

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News Flashes

Instrumental vaginal delivery is preferable to cesarean delivery for women with obstructed labor unless true cephalopelvic disproportion exists, according to a UK study. Researchers assessed the birth-related outcomes of 393 women with obstructed labor who underwent instrumental vaginal or cesarean delivery. Maternal body-mass index, neonatal birth weight, and occipitoposterior position directly correlated with the likelihood of undergoing a c-section. Compared with women who underwent vaginal delivery, women who underwent c-section were 2.8 and 3.5 times more likely to experience major hemorrhage and have an extended hospital stay, respectively. Vaginally delivered infants were less likely to be admitted to intensive care. Regardless of delivery method, major hemorrhage was less likely when the delivery was performed by more highly trained obstetricians.

- Lancet 2001;358:1203-1207


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Hemorrhage

The third lesson about hemorrhage I learned from my mentor was how to properly massage a uterus. Everyone has been trained to massage the fundus, but it is rarely the fundus that bleeds! When the uterus pulls up on itself in labor, it 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 action 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 even touching the fundus is to evaluate how elevated it is in the pelvis as a landmark. Massage the sides, and please be aware of your touch. We have all seen the tortuously painful uterine dominatrix, the one who turns the woman pale with pain. This is plain cruelty! The massage should be firm but gentle.

- excerpted from "Some Thoughts on Postpartum Hemorrhage," by Lisa Goldstein, CPM, CNM, Midwifery Today Issue 48

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The third key to preventing postpartum hemorrhage is to not rush the delivery of the placenta. Almost all postpartum hemorrhages 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 placenta delivery can cause lobes to be left on the uterine wall, which results in uneven contraction of the uterus. These lobes must be manually removed to prevent postpartum hemorrhage and infection--not fun for the mother or the midwife. A policy of hands off, unless there is due cause, is the most important key to preventing postpartum hemorrhage.

- excerpted from "Three Keys to Avoiding Postpartum Hemorrhage," by Margaret Scott, CPM, Midwifery Today Issue 48

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The maternal vessels that nourished the pregnancy will not be able to contract and control the bleeding until the placenta is out of the way. These vessels have been wide open in the final weeks of pregnancy, with a pint of blood a minute coming through the placenta. The crisscross muscle fibers of the uterus, which have been called "living ligatures," tighten in around these vessels to close them off; the vessels themselves draw in and close down where they were severed with placental separation, and the blood coagulates, blocking further flow.

If the placenta is retained without bleeding, evaluate carefully before making attempts at delivery. Mark the top of the fundus and watch it to see if it is rising, suggesting concealed blood loss. If it is not rising, and there are no signs of blood loss, the situation is stable. Partially separating a placenta that is abnormally adherent and then being unable to complete delivery means that a site for bleeding has been opened up. The bleeding is unlikely to stop until the placenta is completely delivered.

If hemorrhage occurs with the placenta out, direct pressure by external or internal bimanual compression of the uterus will stop the flow of blood while other measures are being taken to help the mother's system work. These may be fluid replacement, herbs or medicines, or simply getting the baby to nurse to encourage uterine contraction. It is best to use manual methods to prevent further loss while a second attendant gives Pitocin or shepherd's purse. Expressing clots may be necessary to stop the bleeding.. They can mechanically prevent the uterus from contracting effectively, same as the retained placenta, causing continued blood loss.

- excerpted from "Hemorrhage during Pregnancy and Childbirth," by Marion Toepke McLean, Midwifery Today Issue 48

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MIDWIFERY TODAY ISSUE 48 is a veritable manual about hemorrhage.


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Anyone out there breastfeeding with either a current or past nipple piercing? I bet it's awfully messy but works just fine. What do you think?

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Q: Would readers please share their experience with and information about endometriosis and pregnancy/labour? Our pregnant client has quite severe endometriosis with nonpregnant symptoms of frequent nausea, very painful cramping premenstrually and during menstruation, heavy bleeding, and bleeding from the rectum.

- Anon.

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Question of the Week Responses

Q: Has anyone developed her own system for newborn gestational age assessment? The New Ballard Scale seems more elaborate to me than is necessary for term babies who are born at home. I know that experienced midwives can quickly look over a baby and estimate the gestational age, but for now I would like to find a concise format to document characteristics for EGA.

- Amy Kieffer, student midwife

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A: Many things are unnecessary and actually a little cruel or disturbing to a sound baby and tend to check only simple things like creases, ear coil, breast buds, lanugo, vernix. I, however, stay away from the scarf sign, leg lifts, wrist bending, etc. Today I needed to add a five-day-old baby's gestational age to his birth certificate. I gave him a 38-week gestational age, yet in retrospect believe he was a 40-weeker. I used all the text info, and did most of those disturbing things to reach this guestimate. I do think that after a homebirth, why muck it up with statistical info? I'd rather stick to noninvasive measures. But I won't make a mom or a baby upset after a great, nonintrusive homebirth.

Please let us know if anyone has drawn up a better plan for those of us who feel the Ballard scale is too much.

- Heather Zanon
Wisconsin


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Re acupressure [Issue 3:45]:

When I delivered my first baby, a midwife pressed my little toe to encourage contractions. Every time she did this the contraction was enormous, so much so that I kicked her away and I think I may have even sworn at her (just a little). It did do the trick though. That was at Princess Royal Hospital, Haywards Heath, West Sussex, England.

- Anna Reeve, student midwife
Guisborough, England

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I went to 42 weeks pregnancy and my OB threatened induction, so I tried everything (eating curry, sex, nipple stimulation, etc.). My mother suggested she do some reflexology (she is qualified). She told me that parts of my feet represent my body and the squidgy inner parts represent my uterus, which is why it looked swollen. I remember she touched my toes, too. Most of it was stroking movements. The next morning my waters broke!

Halfway through labour my contractions stopped and once again I was threatened to be induced the next day. My mother came over again and did some special reflexology tricks and labour started again later that night, although the hospital had told me labour had completely stopped because I was having only about one contraction an hour. I gave birth that night, with only gas and air. I also had no injection for the placenta, which I delivered about 5 minutes after.

She suggested to my partner that as contractions happen, push against the tight part of my foot. This didn't remove the pain but balanced it out a bit.
My mother also mentioned that it is possible to cause more harm than good if you don't know what you are doing, so get training first!

- Debra

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The big toe is an acupressure point for the pituitary. In theory, stimulating this point would release oxytocin and facilitate the separation of the placenta.

- Lynda Comerate, RN, BSN, LCCE, HBCE

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What value do fetal heart tones have in pregnancy besides reassurance to the mother and midwife that the fetus is alive and well, which we can easily ascertain by fetal movement? Any ideas? Any known research?

- Jennifer Moore, traditional midwife

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Re painful postpartum cervix [Issue 3:45]: I used a homeopathic remedy following the birth of my second daughter that is commonly prescribed for "pelvic trauma." I had an anterior cervical lip that my midwife slipped off the baby's head just before she crowned. After the lochia flow stopped I noticed an ache in my cervix and a burning discharge. My homeopath suggested Bellis Perinis, which worked wonders for me. I am not qualified to offer suggestions on dosage but if your client can find a homeopath, she might begin there.

- Samantha Sering

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I have two children, the youngest 16 months old and his sister 27 months older. I'm having issue with the vertical muscle in my abdominals that separates from sternum downward to accommodate pregnancy. Both of my midwives assured me that it would heal if only I concentrated on doing some sit-ups every day. I'm not overweight or unhealthy and I do exercise, but it hurts to work that part of my stomach because it's split so far open. It never healed between my two pregnancies and it's yet to even close up a little bit since my son's birth (if I sit up a little from lying down, I can get three-plus fingers in the gap.) It hurts and I have a hard time lifting. My mother seems to have the same problem. Does anyone have any idea what I'm talking about and/or what could be wrong? Will this be a problem for me if I get pregnant again?

- Lisa

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I am a first-year student midwife studying in England. I read an article in a "baby magazine" aimed at mothers (not midwives) about a technique of nipple piercing which enabled a mother with inverted nipples to breastfeed (with the piercing in place) because it held the nipple outward. Has anyone heard of this technique? A literature search and questions to my tutors have revealed no further info and I've lost the article.

- Anna Reeve
Guisborough, England

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I was greatly heartened to read Ms. Bjorkland's response [Issue 3:44 & 45]. I shared many of the experiences of both the sister-in-law and the laid-back woman. I went into my fourth pregnancy with great joy and since I had already had two very easy pregnancies and births (less than two hours of labor, unmedicated). I felt I had nothing to fear. Imagine my surprise at 27 weeks as I developed nephritis. I stayed sick for the rest of my pregnancy. I clinically developed nephritis three additional times. At about 34 weeks I began to sense something was not right and began to question my OB. Finally just to humor me he ordered weekly nonstress tests, which were inconclusive for two weeks and then at week 36 showed my baby in significant distress. We attempted to be induced but ended with an emergency c-section. My baby had the cord around his neck three times and my placenta had several large areas of infarctions. My OB later told me that he was grateful that I was as vocal as I was and that he had learned to listen to his patients.

Since my son's birth I have gone on to become a practicing labor and delivery nurse, currently studying for my lactation consultant's exam. I am always so surprised at my colleagues' reaction when I share this particular birth experience. At the time there were no midwives practicing in my area but the midwives who are here now in particular have tended to act like I brought that whole experience on myself.

A judgmental attitude closes doors of communication faster than just about anything. I have found in my practice that the more I stand back and let the parents tell me how they feel and what they sense about their baby, the more wisdom both they and I develop.

To automatically assume that because a woman is tense or worked up about her delivery and so deserves a difficult labor is wrong. How much better would it be if we could reach out in compassion and say "What can I do to help?" How blessed I was to have a doctor who listened to me, a partner who listened to me, and two nurses who served as advocates for me. My son is now 16 and a true walking miracle.

- Karen Madsen, RN, lactation & childbirth educator

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Many of us in the natural childbirth community (especially in the out-of-hospital community) lack compassion for women making choices other than those we recommend. Consciously or unconsciously, we look down on or judge women who desire high-tech birth. Our attitude about their choices colors our interactions with them. How can we expect a woman to believe in the beauty and safety of natural birth when she's being treated in an unsafe, unloving way? How can we expect our choices to be respected when we are disrespectful to the choices made by others?

When I talk to a woman planning a (by my standards) high-tech, high-intervention birth or a woman allowing her provider to plan such a birth, I try to remember that I am an advocate of informed *choice*. Each woman has a right to choose the birth experience she wants/needs regardless of my opinion of the quality of information she's basing that choice on and certainly regardless of my opinion of her choice. If someone wants more or different information, I make it available. Otherwise I try to act as a mirror: allow the woman to examine her choices by bouncing them off me.

I am not a homebirth midwife because I believe every woman should have a homebirth. I am a homebirth midwife because I want to make the option of homebirth and independent midwifery care available to families who want this experience. I respect all families and all choices.

Each of us--midwife, doula, MD, nurse, client, student--should strive to treat everyone with respect and, if we can muster it, love.

- Melissa Jonas, licensed midwife

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