Efficient management of postpartum haemorrhage is one of the wonders of modern obstetrics. The key is the availability of oxytocic drugs, which make the uterus contract down and normally stop bleeding. The drug most commonly used is Syntometrine - a mixture of Syntocinon (synthetic Oxytocin) and Ergometrine, but Syntocinon or Ergometrine can be used separately as well, depending on the circumstances.
1. What can a midwife do about heavy bleeding at a home birth?
The brief answer is, the midwife would follow exactly the same steps that she would take in hospital. Oxytocic drugs to manage blood loss are part of the basic kit that midwives take to every home birth. If these did not bring the situation under control quickly then an ambulance would be called, and the midwife would take other steps if necessary, such as manually compressing your womb to stop bleeding. In the UK most midwives can put an intravenous drip in at home while they are waiting for an ambulance to arrive.
Here are some comments from experienced midwife Mary Cronk:
Treatment of severe PPH out of Hospital
Remember this is a highly unlikely scenario in a physiological labour, but it can happen and has happened to me.
Depends on when in the third stage it happens. If the placenta is in situ and there is heavy abnormal bleeding the drill should be something along the lines of:
1.Get help ie send for a paramedic ambulance. If, when it turns up all is well, it can return to base, but have it coming.
2.Give an oxytocic drug - either Intramuscular Sytometrine or Intravenous ergometrine - and attempt controlled cord tractrion IF the fundus has contracted and you feel that the placenta has separated. But if there is resistance do NOT keep pulling on the cord. The oxytocic will contract the uterus, stop the bleeding and if there is any possibility that this is a morbidly adherent placenta the place to deal with it is in an operating theatre.
If the placenta is out and the Mum starts to bleed heavily the drill is much the same:
1.Send for help
2.Rub up a contraction ie massage the top of the uterus to stimulate it to contract
3.Give an oxytocic drug. If this does not stop the bleeding, and it usually does, then put up an IV. If transferring, the midwife or paramedic should set up an intravenous infusion prior to transfer so that there is a vein open and ready for easy access if necessary.
4.I would use either one of the blood expanders Haemocel or Gelufsen, if the blood loss had caused a deterioration in the Mum's condition, shown by a rapid thready pulse and a fall in BP. Or something like Hartmanns solution , if she was fine and it was just a precautionary IV.
In both cases, if you have a cooperative baby, get the little darling to suckle.
What if the midwife isn't there?
EMidwife Kerrianne Gifford has advice for any woman who suddenly finds herself bleeding heavily after birth, where no midife is present. This could occur if the baby was born suddenly before help arrived, or if the midwives have gone home when bleeding suddenly starts. It could also be useful for women who give birth in hospital, and suddenly find themselves bleeding when they have gone home.
Emergency PPH care at home, by Kerrianne Gifford
When the midwife arrives:I would say to any woman who is having bleeding which, for want of any other description, "is reaching her toes very fast" or "gushing" or "soaking pads 1,2,3.." and there is no midwife present then call emergency service 999 immediately. Then mother tries, if conscious, to massage her uterus herself to the point that it feels very firm and rounded, bleeding will sometimes stop instantly. Make sure she has passed urine.
If she has help then there is a technique called bi-manual compression. In the absence of immediate midwifery help it would be worth anyone trying it if the woman is bleeding catastrophically with a pph. It means someone having to continually compress the uterus externally and internally until help arrives.
There are a number of things that a midwife does once she arrives.
She considers what we call the 4 T's: Tone, Trauma, Tissue and Thrombin (clotting) factors.
She can make sure the woman has passed urine and does not have a full bladder. She can use massage of the uterus, syntometrine or ergometrine medication to try stem bleeding. These medications induce a sustained uterine contraction. The massage of the uterus will sometimes expel any tissue obstructing good uterine clamp-down.
The midwife will check for an unusual tear that may need immediate suturing and haemostasis.
Also midwife or paramedic who I assume is also on the way or present will be inserting venflon and paramedic can start intravenous fluids. Any clotting factor issue will need specialised therapy and blood products available in the hospital.
Bi-manual compression will be used and transfer to hopsital will happen as soon as an ambulance gets to the home if bleeding is not stemming.
If bleeding has beed easily stopped and woman feels fine then she may end up declining transfer to hospital. However in hospital they can offer a number of extra helpful interventions for anyone who has experienced or is experiencing a life-threatening PPH.
In other circumstances involving placenta issues, if placenta has only partially separated and is causing obstruction to efficient uterine haemostasis and bleeding is ensuing then a midwife can perform a gentle manual removal in an emergency at home.
If a pregnant woman has a very rare condition called placenta accreta or percreta then hospital care is definately warranted. I am aware of two stories associated with this condition, one with a good outcome and one where the woman died. The one where the obstetrician recommended the placenta was left in situ was fine and the woman eventally passed out degraded placenta a few weeks later.
The other was where woman had unpredicatable catastrophic bleeding from a percreated placenta (previous caesarean section) in the third trimester. Baby lived but hospital couldn't save the woman's life even though they fought for many hours to do so.
Women can do something to help themselves if haemorrhaging and midwives do have the necessary skills to attend any unpredictable emergencies at home. As with all things in life though, good outcomes are not fully guaranteed at home nor in hospital.
In my experience, on the rare occassion when there is a PPH after a home birth it is usually dealt with successfully with mother and midwifery co-operation and skills.
Can more be done in hospital to treat a PPH than can be done at home?
From independent midwife Carrie McIntosh:
Yes, there is more than can be done in hospital to deal with a PPH, mainly because of the numbers of staff around. It all seems to happen very quickly in a hospital situation as well - it is a well choreographed scene and a daily occurrence in labour ward so they are well used to it. It's not to say that the things that are all happening around a PPH in hospital are always crucial in that they must be done there and then. A lot of things are done "just in case", which is fair enough, but in a home birth situation, your priority is to identify your source of bleeding and deal with it as quickly as possible with the tools you have whilst getting someone (partner) to call ambulance).
Most homebirth midwives would not be considering setting up a drip at home because the hands needed to do that are far better doing other things to stop the bleeding. The drip can be set up in the ambulance en-route.
The most common reason for PPH is to do with atonic uterus, where the womb fails to contract down properly. At home, this is dealt with in the same way and with mostly the same drugs that would be used in hospital.
It's important to mention that PPH at home is reasonably rare, by the very nature of the fact that the major risk factors for PPH are things which only happen in hospital (instrumental deliveries, long hours on syntocinon drips, caesarean section etc).
In fact, there has never been a case in the UK as far as I am aware of a woman dying from PPH at a home birth (in recent years). The last confidential enquiry into maternal deaths listed I think 5 deaths from PPH, all of which were in hospital, four of them were following instrumental deliveries and one following caesarean.
How likely is post-partum haemorrhage after a home birth?
Postpartum haemorrhage (PPH)is significantly less likely to happen after a home birth than after a hospital birth. Partly this is because women at high risk of haemorrhage will normally have transferred to hospital before or during labour, and partly it is because planning a home birth seems to reduce a woman's risk of having a postpartum haemorrhage overall, regardless of where she gives birth eventually. This is probably because home birth reduces the risk of interventions which can contribute to postpartum haemorrhage.
Part of the reason for higher rates of blood loss after hospital birth is that PPH is statistically more likely to occur after intervention such as caesarean section, assisted delivery (forceps or ventouse), or medical induction or augmentation of labour (having a drip to speed labour up). None of these things will be happening at home. If you were to have any of these interventions, you would already be in hospital.
There are some ways in which planning a home birth actually reduces your chances of having a PPH. We know that simply planning a home birth significantly reduces your chances of ending up with a caesarean or an assisted delivery (eg see the National Birthday Trust Fund study) - labour just seems to progress more smoothly at home, leading to less call for intervention. As these interventions increase the risk of PPH, by reducing the risk of the intervention, you are reducing the risk of PPH.
If a woman has a previous PPH, can she have a home birth for her next baby?
Here is a post of mine from a discussion on the UK midwifery group - a bit rough and ready, I'm afraid:
To try to work out the chances of a PPH recurring, and whether this is 'safe' for a home birth, you'd need to know why the PPH occurred, and if the same circumstances were likely to recur. Usual caveat: I'm not a midwife! However, if I were, I would be wondering:
1. Was the PPH significant for her, or was it just a 'technical' PPH? eg I had 500mls caught in the dish after my first baby was born at home, plus plenty more in the birth pool, all over the floor, etc, but I felt OK and was off up the high street the next day. As a strapping lass, 500mls + clearly wasn't that bad a loss for me. On the other hand, after losing around 3 pints during a miscarriage, I felt dizzy and breathless for a couple of weeks afterwards.
Midwives on this list have often commented that they prefer to base their definition of PPH on how the woman feels - some feel awful after losing just 300mls, others recover quickly from a much larger loss. What is the definition of PPH in your hospital? Some use the old UK standard of 500mls +, while others now seem only to record blood loss over 1,000 mls, the criterion which is more common in Europe.
2. What were the circumstances the PPH occurred in? Were there known risk factors for PPH which would not apply this time? For instance, PPH is more common after assisted deliveries, first babies (I suspect possibly because more assisted deliveries), large babies, induction or augmentation of labour. If she needed an assisted delivery this time she would transfer to hospital, so that shouldn't affect her status as regards home birth. Likewise, her labour is not going to be induced with prostaglandins or augmented with syntocinon.
3. Was the PPH a 'true' PPH in terms of being blood loss from her uterus, or was it associated with perineal tearing or episiotomy? Blood from both sources ends up in the same measuring jug, but the difference is significant.
4. Was her previous PPH an emergency situation - eg lots of blood spurting out, needing particular treatment to stop it? Or was it a steady flow? How was it treated? If she was given Syntometrine, did she respond well to it? Or did she need some treatment that you would not be able to give at home?
5. Did she have a retained placenta, or did the bleeding occur after the placenta was delivered - some 'uterine atony' involved?
You may be able to find stats on the likelihood of a repeat PPH occurring, but unless you know more about the circumstances, I suspect they wouldn't be very useful to this woman, or to you. There could be a great difference between the risk of a repeat occurrence, depending on the circumstances.
Birth Stories involving PPH or retained placenta, transfer in the third stage, or home birth after previous PPH
Fran had a PPH of 1,000mls after her first baby's birth in hospital, and had to fight for a homebirth with her second as a result. After a much gentler home birth, she lost only 300mls.
Cassandra had a retained placenta and manual removal after her first (hospital) birth. She was worried about this stage of labour when she gave birth at home, but had no problems.
Jillian's second baby was born at home after a very positive labour, but she bled heavily after the birth and transferred to hospital, where she continued to have very severe blood loss until fragments of retained placenta were removed. Jillian writes :
I'm saddened by the fact that people who don't know the full story of this birth seem to assume that I had a PPH because I gave birth at home, and that I nearly bled to death at home. Actually I nearly bled to death in hospital, if anywhere, but they don't seem to be able to hear that - I lost an estimated 750ml of blood at home before the ambulance arrived, then I lost an estimated 1500-2000ml of blood in hospital before they decided to give me a spinal and take me into theatre.
Kedi gave birth to her large third baby in water, at home, and wanted to deliver the placenta in the birth pool too. However, the third stage proved to be painful and tiring, and it took two hours to complete. Nonetheless, she managed it at home.
Lucy gave birth to her first baby at home, after a three hour second stage. She transferred to hospital for observation because of heavy bleeding afterwards. Her second baby's birth, just 16 months later, was very straightforward - no trouble with the third stage at all.
Juliet had a very positive, gentle home birth for her first baby, Florence, but later transferred to hospital for manual removal of the placenta.
Amy Driver's first baby, Ella Hope, was born at home after a straightforward labour, but Amy transferred to hospital after the birth because of heavy bleeding. She went on to have a very straightforward homebirth for her second baby, Lucy, with no problems.
Helen Gardner transferred to hospital after a home birth to have some stitching, but her triumphant story makes it clear that this has not marred her memories of the birth.
Joanne King gave birth at home and had a managed third stage, but was still bleeding because of retained placental parts. This was managed at home with further use of drugs.
Sarah Sadler had a home birth and wanted a physiological third stage, but, after waiting for the placenta for an hour, decided to use Syntometrine instead.
Elizabeth had a homebirth for her first baby, but undetected retained pieces of placenta caused heavy blood loss after the birth. She ended up transferring to hospital five days later.
Karen transferred to hospital after the birth of her first baby because of a retained placenta, but her second baby's birth was more straightforward. She wrote that, after the birth, "I did not want to birth the placenta, after the retained placenta of last time I quite dreaded this bit, and couldn't believe that I would have a normal 3rd stage.". She did!
Buffy's fourth baby, Lori, was born at home safe and well, but Buffy had a retained placenta and transferred to hospital with very serious blood loss. Buffy has written the story of her third stage on a separate page. She planned another homebirth for her fifth baby, Theo, and this time everything went swimmingly.
Emma Laing was advised to transfer to hospital when she bled heavily after her third baby's birth, but she chose to be observed at home instead.
Colleen is in the USA, and after a straightforward birth, she had a severe postpartum haemorrhage when fragments of placenta were left in her uterus. She transferred to hospital and had a manual removal of the placental fragments without anaesthetic.
Chris C gave birth to her second baby at home, on a lovely home-made birthing nest, and the birth itself went very well. However, she had a serious postpartum haemorrhage and transferred to hospital afterwards; Chris reminds us to consider emergency access to the room chosen for birth.
My own experience of haemorrhage at home and in hospital, after birth and miscarriage
I had a spontaneous, hands-off home waterbirth of a 4,250g (9lb 6 oz) first baby, Lee, with a second-degree tear straight down the midline of my perineum. It was about an hour until I delivered the placenta, and for quite a lot of that hour, the midwife thought the placenta was detached and was just sitting there, waiting for me to push it out. However, having just delivered this stonker of a baby, I couldn't feel any contractions and didn't know how to push it out. At this stage there was little bleeding apparent, but it turned out clots had been building up behind the placenta. I didn't want syntometrine.
After a while there was a big gush of clots, and shortly afterwards, the placenta. The bleeding stopped straight afterwards and the midwives were happy to leave me after an hour or so. They measured 500ml of clots and blood caught in the measuring jug, but there was quite a lot more in the birth pool, all over the tarpaulin on the floor, and in the bidet where I sat to deliver the placenta.
With my next birth, I'd learnt a nifty technique for pushing the placenta out, which was to try to do a poo as soon as it seemed to have detached! This worked wonders (in that it produced placenta but no poo!), and I had negligible blood loss - 100mls - and a very short, natural third stage of 10 mins or so.
After my second baby, I had a miscarriage at 12 weeks. The baby had died at 10 weeks, and I started to bleed at 12 weeks. I miscarried at home, and then had gushes of about 100mls blood every 10-20 minutes. Went to hospital when it became clear the bleeding wasn't stopping. Was rushed through Casualty and put on a drip, but because they were busy and there was a misunderstanding between staff, and there were no beds on the ward, had to wait 4 hours in a cubicle until I was given Ergometrine to stop the bleeding. Fortunately my bleeding slowed dramatically, but was still continuing at a worrying level. I estimate that my total blood loss was at least three pints - I had two pints in a bucket at home and plenty more in hospital, but nobody measures in A&E. Discharged myself the next day, and then had several weeks of feeling extremely breathless and tired while I recovered from the blood loss.
While I was lying in my hospital cubicle, I kept thinking how much safer my home births had been than this miscarriage. At home I had at least one midwife there, solely responsible for me, throughout my labour. If I needed drugs, my midwife would have given them to me immediately. She would not have left me alone until she was sure I was safe.
When my third baby was born, the midwives were on the alert for bleeding because of my history, but in the event my third stage was fast and safe. I lost about 150mls of blood and it took about 10 minutes to deliver the placenta. Fourth baby - another straightforward third stage of about 10 minutes and estimated 300ml loss, and 5th baby, about 15 min and hardly any blood - estimated 50mls at most.
UK Midwifery Archives - emergency management of postpartum haemorrhage (www.radmid.demon.co.uk/pphemergency.htm )
World Health Organisation guidelines on emergency management of PPH
Virginia Howes, of Kent Midwifery Practice, had a client who had a significant PPH at home after giving birth to a 12lb baby. The haemorrhage was stabilised at home, and the woman transferred to hospital for a check-up. I thought this was a particularly interesting case, and so interviewed Virginia about it for her blog. The interview includes a detailed discussion of the case, of how serious the PPH actually was, how the midwife knew whether the woman was compromised or not, and of how the midwife worked with paramedics, and interactions with hospital staff after transfer. You can read the full story on the Kent Midwifery Practice Blog.
WHO (World Health Organization) 1994. Mother-Baby Package. Implementing Safe Motherhood in Developing Countries.