Research to Remember
A procedure to halt severe postpartum hemorrhage and provide an alternative to hysterectomy involves blocking the uterine artery. In a new procedure, a catheter is inserted through a small incision in the patient's groin, and a tiny balloon is inflated in the artery to immediately stop the bleeding. Microscopic plastic particles are then released through the catheter; they travel to the uterine artery to temporarily obstruct it. Embolization therapy alone has been shown in published research to be 80% effective; a Stanford study of 11 women underscores the effectiveness of adding balloon occlusion for further effectiveness. In the study, 9 avoided hysterectomy, 7 had balloon therapy followed by embolization, and 2 had only balloon therapy. Two of the women had a hysterectomy; they had not had balloons placed and their bleeding continued despite embolization.
Hysterectomy following postpartum hemorrhage is said to be the second-bloodiest procedure after cardiac surgery.
— HealthLink, healthlink.mcw.edu
SPECIAL OFFER TO E-News Readers: Subscribe to Mothering Magazine for only $17.95.
That's $5 off our regular price of $22.95 for a one-year subscription! For almost 30 years, Mothering has been the source for sound alternatives to mainstream parenting practices. Articles in Mothering cover the topics of pregnancy, birth options, breastfeeding, vaccinations, childhood illness, alternative health, education, organic food and balancing work and family life. Sign up for a discounted subscription.
Postpartum Blood Loss
Pregnancy is the only time in a person's natural life in which the blood flows out of the intact circulatory system. By full term the amount is impressive: 500-800 milliliters (mL) per minute, which is 10–15% of cardiac output. After childbirth, the size of the uterus shrinks rapidly; the active uterine muscle contracts and tightens itself, and the placenta is sheared off along a natural line of cleavage, the deciduas basalis. This is the point at which blood loss occurs. In the vast majority of births, this blood loss is minimal, and no harm occurs to mother or baby. Up to 500 mL of blood loss (about one pint) is considered normal.
The human body contains approximately four liters of blood. This amount varies substantially with the person's size. In pregnancy the blood volume increases, averaging six liters at full term. Most of this increase occurs during the second trimester of pregnancy, so the woman who is malnourished at this point (or chronically malnourished) is at a disadvantage when blood loss occurs.
To stop blood loss after placental delivery, assess the source. It could be coming from a laceration instead of the uterine blood vessels, necessitating repair. Is the uterus empty? Clots in the uterus can prevent firm contraction of the muscle, as can retained fragments of placenta or membranes. Blood loss is stopped by contraction of the uterus and by normal clotting of the blood in the placental site, which shrinks from the size of the intact placenta to just a few centimeters across as the empty uterus contracts. Shepherd's purse and red raspberry leaf are natural aids to this process. Angelica can help the uterus expel retained fragments.
Don't fall victim to the following all-too-common scenario: The placenta may or may not be delivered. A trickle of blood persists; the attendants can't get it to stop. They watch and wait. The blood pressure is good. She seems to be tolerating the blood loss. "She's a strong woman," they assure themselves.
But the body has many mechanisms to protect itself from shock. The pulse is actually a more sensitive indicator of impending danger than blood pressure, and a steadily rising pulse rate may warn us that it is time to act. If blood loss persists, the mechanisms will fail, and the woman will rapidly go into shock.
An emergency transfer occurs. In the hospital, the woman's condition is found to be so critical that blood transfusion must be given before she is stable enough to undergo procedures to stop her hemorrhaging. Even getting intravenous access is difficult when shock has occurred. Also, if the placenta is still in, she faces additional blood loss with placental delivery. Don't put a woman into the dangerous position of already being seriously depleted of blood with the placenta still inside! Learn to assess blood loss and observe for it critically at every birth.
— Marion Toepke McLean, excerpted from "Unchanging Protocols," Midwifery Today Issue 73
TO LEARN MORE ABOUT HOW TO ASSESS BLOOD LOSS, order Midwifery Today Issue 73 to read the remainder of this article. Go here.
Hemorrhage before the complete birth of the placenta can be very severe and happen without much warning. In this case the uterus is still supplying the placental bed as if it were supporting the life of a term fetus, with the normal 500 cc per minute of blood flow. The uterus, however, has released the baby, but because of the lack of placental detachment, it is failing to contract as it should under this circumstance. The uterine wound of the detached area will be pouring out blood. You must act quickly in this event. Resist the temptation to pull too hard on the cord as a way to extract the placenta. Some cords are quite fragile and can tear off, leaving you in a much more difficult position.
If the mother is slim enough and there is not an abnormally attached placental area, you may be able to get this placenta to detach by an action that resembles squeezing a cherry to pop out the pit. Both hands are placed on either side of the uterus (not on the fundus) and begin compressing toward each other. Stand to the mother's side and work with strong steady pressure, slightly lifting the uterus up (toward her chest) while compressing, which will often in itself help the uterus contract and expel the placenta. The pressures of the hands works toward one another, with greater proximity at the top of the uterus than the bottom; in other words, press the mass of the placenta toward the cervix, slightly. Before you begin, explain to the mother what is happening, what you are about to do, and why. The cherry-pit technique seems to work in greater than 60 percent of these cases. If it doesn't and bleeding is brisk, you cannot dally. You must go in after the placenta because 500 mL/minute (or more) loss can deplete the mother within moments. If her condition is weakened and there is time, try to get something nourishing in her to boost her strength. I like to use Vegex vegetable bouillon; I have seen women with no color in their faces pink up when they take the first few sips. Miso broth is also excellent, better still if it has seaweed in it. Giving oxygen to the mother by mask can help increase the oxygenation of her plasma; this appears to give strength to her muscle tone as well as improve her status in general.…
One postpartum trick I learned is to "blot and count." That means when you are observing the mother's vaginal bleeding after the placenta is out, you blot the stream and count how many seconds pass until it starts to bleed again. It should be three seconds or longer. Anything sooner than this is too much bleeding. It often is those subtle trickles of bleeding that are the most dangerous. Women have been known to slowly bleed to death in their sleep, especially if given pain or sleeping medicine. The rapid gushers are obvious; the insidious trickles are not. I have read that death from a postpartum hemorrhage occurs an average of five hours after the birth.
Another lesson on hemorrhage is how to properly massage a uterus. Everyone has been trained to "massage the fundus," but it is rarely the fundus that bleeds! Obstetrical or midwifery textbooks contain illustrations of how the uterus pulls up on itself in labor. The fundus 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 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 ever touching the fundus is to evaluate how elevated it is in the pelvis as a landmark. The massage should be firm but gentle—you don't want to create pain.
— Lisa Goldstein, gleaned from "Some Thoughts on Postpartum Hemorrhage," The Hemorrhage Handbook, a Midwifery Today book
Products for Birth Professionals
Show your father what he means to you.
Give him the Father Spirit Clay Sculpture. This two-inch sculpture comes with a removable baby and celebrates nurturing fatherhood.
Buy the Father Spirit Clay Sculpture and get Midwifery Today Issues 8 and 51, on fathers, for just $5 more!
Or, buy just the two issues for the special low price of $10 for both.
More information about gifts for a father.
Save on a specially selected Midwifery Today product.
Take advantage of the current coupon special.
Give the gift of information!
You'll save $5 per subscription when you order two one-year Midwifery Today subscriptions at the same time. And one of these can be your own renewal or new subscription!
Web Site Update
The dates for the upcoming Midwifery Today conferences in Philadelphia, Germany and Eugene are now posted on our Web site. You may also view the themes and some teachers and classes being offered for Philly and Germany. Conferences: Looking Ahead
Read this article newly posted to the Midwifery Today Web site:
Read this review:
I have been shown to have APA (antiphospholipid antibodies) and I am now on Lovenox and one baby aspirin a day. I am also on progesterone and biweekly HCG and progesterone testing. My last miscarriage was in February at 13 weeks and was emotionally hard to handle, so I am OK with the precautions we are taking now. Does anyone have ideas about how to "handle" Lovenox or other blood thinners with a homebirth (I don't know if I'll be changing meds at any point or going off them altogether).… Is there any information out there about the risks involved in going off the meds close to birth? Does it lead to immediate clotting?
Share your thoughts and experience about this topic.
**Please do not send your responses to E-NEWS!**
Seeking CNM with full commitment to the process and philosophy of normal birth. Blend your love of midwifery with a delightful, full-scope practice that "listens to women" with an excellent, supportive physician who believes in the midwifery process! Join us for hospital births, VBACs, homebirths and in our freestanding birth center in Fort Myers, Florida, opening Autumn 2005. Fax CV to Mary Kay Miller (239) 561-9188. Call (239) 994-9191.
Help Our Sister Midwives
Gentle Births for a Peaceful Future
Robin Lim founded Yayasan Bumi Sehat. It is a not-for-profit organization of committed families, teachers, midwives, doctors, nurses and caring citizens from many countries.
As a not-for-profit organization Yayasan Bumi Sehat has had to rely heavily on the kindness and generosity of others without whom they would not be here today. With the disaster of the tsunami, many midwives have perished. Those that survived are in desperate need, as many families need their help. The many heroic stories are sad, beautiful and touching. Please reach out and contribute whatever funds you can now.
Please make checks to:
P.O. Box 45
Gates, OR 97346
Jill will be making a direct deposit to Yayasan Bumi Sehat's account in Indonesia by June 15, so please do not delay!
Call for Testimonials for Jeannine Parvati Baker
Would you be willing to write a letter that informs the Liver Transplant Team about my life of community service? Please be as specific as you can as to how your life was affected by mine. Cite the location, circumstance and your credentials. Keep your letter under one page. Ask the Transplant Team to place your letter in my file.
Remember that you are writing to a conservative medical board and so choose your words wisely. For example, if we met via the freebirth community, just say "childbirth" instead. Please show me your letter before you send it. Send it to me priority mail or by e-mail. Send a copy of your letter to Jeannine Parvati Baker, 10 N. State St., Joseph UT 84739 or e-mail it to email@example.com. Once you hear back from me, please send the letter directly to the name and address below:
Liver Transplant Team
324 10th Ave. Ste. 24
Salt Lake City, UT 84143
Question of the Week (Repeated)
Q: A client has a degenerative kidney disease called IgA nephropathy. She is showing +1 to +2 protein in her urine, her average blood pressure (BP) is 130/82. She is seeing a nephrologist and getting her labs done monthly: sodium, potassium, chloride, carbon dioxide, calcium, glucose, phosphorus, BUN and creatine, albumin—all of which are in a normal range. I am looking into alternative methods for supporting and nourishing her kidneys through the pregnancy. She has seen an acupuncturist (per my suggestion) one time to receive treatment and herbal supplements. She is 20 weeks pregnant. In addition, we helped her with a homebirth 2-1/2 years ago, and during that pregnancy she had no protein that spilled in her urine and her BP was more like 110/66. Do readers have recommendations and/or experience?
SEND YOUR RESPONSE to firstname.lastname@example.org with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.
Question of the Week Responses
Q: Recently, as an L&D nurse, I ended up delivering a double-footling breech baby. I received some criticism from another nurse that I should have let the baby's head remain in the vaginal vault. She states that it is OK to leave such a presentation for up to an hour. The OB who came in later said, You have four minutes to get the baby delivered. Who is correct? I entered into this delivery at change of shift, and patient was in triage area awaiting a surgeon for c-section. I was presented with two feet and buttocks out of the perineum.
— Gretchen Jenkins
A: Always make sure baby is not distressed by checking heart rate. If all is fine, it is appropriate to leave baby to birth in its own natural time. You would of course need to check for prolapsed cord. I guess in hindsight you would be asking the obstetrician the reason for the decision that baby needed to be out in four minutes. Was this because of trauma, was it standard hospital procedure, or was it his/her own fears coming into play?
The main issue is that the mother and baby are in good health physically and emotionally from their birth experiences, and that you yourself know in your heart that you did what you believed to be right at the time for the situation you were presented with.
A: The obstetrician was correct. Once the head moves down into the birth canal, the cord, which is going up beside the head, is flattened and the baby is no longer receiving adequate oxygen supply. Congratulations on a successful delivery!
— Judy, CPM
Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to email@example.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
How do nurses figure out when a new week of pregnancy starts? For example, if a patient is 35.6 weeks pregnant, is the next day considered 36.7 or 37 weeks pregnant? How is the exact number of weeks and days figured out when a patient is first admitted?
I have a pregnancy wheel but I don't understand how you determine the exact number of weeks and days pregnant someone is. I am a med/surg nurse and am very new to ob/gyn. I notice the nurses giving other nurses exact weeks and days pregnant but just don't understand how to calculate and keep track of weeks and days. Can readers please explain it to me?
For more than 20 years, the nonprofit organization Population Communications International (PCI) has been assisting local talent develop educational and entertaining radio programming. PCI-assisted programs have won international awards for excellence and have become the most popular radio programs in numerous countries.
In 2005, PCI is offering workshops in Guatemala, Mexico and Peru to those who are interested in learning more about the field of entertainment education (EE) and how to produce effective radio programs, including radio serial dramas. Those who successfully finish the workshop will then also be eligible to submit proposals for a seed grant to produce and air their own radio programs.
This is an opportunity for midwifery organizations in Mexico and in Latin America to learn how to educate and promote their cause through the use of mass media. Do not miss out on this opportunity! The first workshop is taking place in Guatemala at the end of May. Get your application in now! Scholarships are available to cover tuition costs for the four-day workshop, room and board.
For more information in Spanish and to download your application please look at: www.population.org/taller
Spanish and non-Spanish speakers can also call PCI headquarters in New York City and ask to speak with Natalia or Nadine at International Programs. The phone number is (212) 687-3366.
— Nadine, Mexico
Editor's Note: Only letters sent to the E-News official e-mail address,
firstname.lastname@example.org, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.
PERINATAL MENTAL HEALTH: A Public Health Issue Conference, 24 June 2005 in Chelmsford, Essex. For further information, please contact Sarah-Jane Mackenzie at 01245 493131 ext. 3163 or e-mail: email@example.com
Midwives wanted for a Birth Center in the Hollywood, CA area. Contact Dr. Christine Anderson at (323) 436-2735 or e-mail firstname.lastname@example.org. For information on Dr. Anderson, go to www.kidchiropractic.com.
Remember to share this newsletter
You may forward it to as many friends and colleagues as you wish—it's free!
Want to stop receiving E-News or change your e-mail address? Or would you like to subscribe? Then please visit our easy-to-use subscription management page.
On this page you will be able to:
- start receiving any of our e-mail newsletters
- stop receiving any of our e-mail newsletters
- change the version (text or HTML) that you receive
- change the e-mail address to which newsletters are delivered
If you have difficulty, please send a complete description of the problem, including any
error messages, to our newsletter.
Learn even more about birth!
Midwifery Today Magazine - mention code 940 when you subscribe.
| ||1-Year Subscription||2-Year Subscription|
|Canada / Mexico||$60||$113|
|All other countries||$75||$143|
E-mail email@example.com or call 1-800-743-0974 to learn how to order.
Or subscribe online.
How to order our products mentioned in this issue:
Secure online shopping
We accept Visa and MasterCard at the Midwifery Today Storefront.
Order by postal mail
We accept Visa; MasterCard; and check or money order in U.S. funds.
Midwifery Today, Inc.
PO Box 2672
Eugene, OR 97402, USA
Order by phone or fax
We accept Visa and MasterCard.
Phone (U.S. and Canada; orders only): 1-800-743-0974
Phone (worldwide): +1 541-344-7438
Fax: +1 541-344-1422
E-News subscription questions or problems:
Editorial submissions, questions or comments for E-News:
Editorial for print magazine:
For all other matters:
All questions and comments submitted to Midwifery Today E-News become the property of Midwifery Today, Inc.
They may be used either in full or as an excerpt, and will be archived on the Midwifery Today Web site.
Midwifery Today E-News is published electronically every other Wednesday. We invite your
questions, comments and submissions. We'd love to hear from you! Write to us at:
firstname.lastname@example.org. Please send submissions in the body of your message and not
This publication is presented by Midwifery Today, Inc., for the sole purpose of disseminating general health information for public benefit. The information contained in or provided through this publication is intended for general consumer understanding and education only and is not intended to be, and is not provided as, a substitute for professional medical advice, diagnosis or treatment.
Midwifery Today, Inc., does not assume liability for the use of this information in any jurisdiction or for the contents of any external Internet sites referenced, nor does it endorse any commercial product or service mentioned or advertised in this publication. Always seek the advice of your midwife, physician, nurse or other qualified health care provider before you undergo any treatment or for answers to any questions you may have regarding any medical condition.
The content of E-News is copyrighted by Midwifery Today, Inc., and, occasionally, other rights holders. You may forward E-News by e-mail an unlimited number of times, provided you do not alter the content in any way and that you include all applicable notices and disclaimers. You may print a single copy of each issue of E-News for your own personal, noncommercial use only, provided you include all applicable notices and disclaimers. Any other use of the content is strictly prohibited without the prior written permission of Midwifery Today, Inc., and any other applicable rights holders.
© 2005 Midwifery Today, Inc. All Rights Reserved.
Midwifery Today: Each One Teach One!