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Postpartum Hemorrhage

Obstetrical #hemorrhage is the most common serious complication of #childbirth and is the most preventable cause of maternal mortality, yet rates are increasing in developing countries, including the United States, and rates of severe hemorrhage-associated severe maternal morbidity are worse than any other poor obstetrical outcome.

One of my first obstetrical emergencies in the homebirth setting was a postpartum hemorrhage. I remember thinking to myself, "what the hell was I thinking wanting to do this!?!" However, after I sat on it a bit, I realized, this woman hemorrhaged more than an hour after her birth, and she had a fairly horrific hemorrhage. Had this occurred in a remote hospital, the physician would have been gone by this point and the nurse would have been out at the desk. When this mother quietly closed her eyes and seemingly went to sleep, I was immediately at her side, already sitting on her bed with both of my nurses. Her husband was laying beside her in bed, and without a word, we all went to work performing our respective clinical responsibilities. Had we awaited transfer, she would have bled out. Had she been in the hospital, she may have bled out before receiving care. This scenario shook me, even after more than a decade of working in tertiary hospitals with high risk clients, but I knew, in that moment, with that mother, she was in the absolute best place. I found some confidence in my setting, but well respected the challenge ahead of me: improving the standards of care for homebirth clientele.

When I was in graduate school, as part of the Frontier Midwifery program, we were required to stay on campus for a few weeks of intensive clinical skill work in effort to prepare us for our clinical internship. We learned to suture, guide an impacted shoulder, place cervical diaphragms, and manage postpartum hemorrhage, among other skills. It was this latter skill that I found most intimidating, primarily because our professor explained that in our country, with the resources available to us, any maternal death would be the result of poor management. It seemed an incredible amount of pressure was placed on us as clinicians to perfectly manage every single case, and to know that my split second decision or lack of decision could result in maternal death was, well, a bit overwhelming - enough even for many to change their mind altogether about moving forward in this profession.

In fact, it was a postpartum hemorrhage in my later practice that shook me to the point of requiring #therapy for post-traumatic stress. Interestingly, it wasn't the case itself, not even the pool of blood that circled this mother's head that I can still see with perfect clarity even today that ultimately caused me to freeze up in subsequent births, it was the fear that in spite of our excellent response and her ultimate recovery, when her family and her community, and even my own professional colleagues, talked of this case, it would be of me being rogue and reckless. It would not be that I managed her care with expertise or that a very rare incidence, a neurogenic bladder, created a horrific scenario that would challenge even the most skilled practitioner. It was the awareness that nurse-midwives, particularly those practicing outside a hospital setting, are looked upon with great distrust and repugnance.

Defining Postpartum Hemorrhage

Historically, an estimated blood loss of more than 500mL after a vaginal birth and more than 1,000mL after a cesarean were considered diagnostic for postpartum hemorrhage, but these are challenged by the very subjective nature of estimating blood loss at birth, and these volumes are somewhat close to the average loss of blood for both vaginal and cesarean births. More recently these definitions have evolved to a "cumulative blood loss of 1,000mL or more OR blood loss accompanied by signs and symptoms of hypovolemia within 24 hours following the birth process," with the note that "cumulative blood loss of 500 to 999mL alone should trigger increased supervision and potential interventions as clinically indicated."

Careful cumulative assessment of blood loss is therefore crucial for proper management of postpartum hemorrhage. Similar to management of shoulder dystocia, it seems the practitioner who finds themself in trouble with these obstetrical emergencies, first deny their occurrence, and then delay their response.

Hemorrhage in the Homebirth Setting

As a homebirth midwife, I am often asked what sort of questions women should ask midwives they are considering for attendance at their own births. There are many, but one on the top of my list is that they show you their equipment. Maybe you won't know all the many things necessary for attending a safe homebirth, but you will recognize the difference between a midwife who has her equipment neatly stored and labeled so she can effectively and efficiently manage emergencies and a midwife who has a rather haphazard assortment of supplies and equipment in her carpet bag.

When it comes to managing a hemorrhage for example, because these items are so rarely utilized, having specific placement and even labels can be helpful for grabbing and preparing these items in a timely manner. The midwife should be well familiar with her system, and even be able to talk you through it with her eyes closed, because this is exactly what she will do to her assistants as she has her hands busy caring for you.

The midwife should also have a consistent system for stocking and maintenance. Her offering an excuse that her equipment hasn't been stocked from a previous birth or are in disarray because of whatever scenario is sure indication of negligence. Midwives are well aware that at any moment, even minutes after walking in the door from a previous birth, we could be called to yet another birth. We need to always be ready and have back-up systems for safe supplies and equipment.

Medication availability should be well organized, safe, and secure. The midwife should be able to discuss with you the necessary storage guidelines for each medications, as some require refrigeration and others have a tight room temperature range. This is important for example, for midwives who live in areas where it may become cold or especially hot in the car. Leaving your birth bags in environments which aren't temperature controlled while evaluating a mom in early labor, or even after returning home from the birth, could compromise their effectiveness.

Another question that I think is appropriate for asking midwives, is about their ongoing training and debriefings. While I think you'd be hard pressed to find a midwife who isn't attending in-service trainings, I think because midwives are very focused on setting a respectful and peaceful birth ambience and overall, positioning themselves as fierce and passionate advocates, they aren't always prioritizing clinical training. Midwifery gatherings are often little more than a gathering, full of kumbaya, for refueling the midwife's tired soul.

Consider though, that because most choose homebirth to avoid these interventions, midwives are put in a position of having to defend against claims that she is too-interventive or is a med-wife, yet what you really seek when hiring a birth attendant, is someone who can save you and your child in an obstetrical emergency. You don't simply want someone who can dial the paramedics, and you don't need someone to set the right ambience for your birth. These are tasks you can either take upon yourself, or hire someone far less expensive to manage. What you really want when you hire a midwife is the most skilled clinician available, who can drop an IV in your arm and administer emergency fluids when you are hemorrhaging. You want a midwife who isn't too timid to perform advanced skills that intimidate even the most experienced obstetricians, because she is your only lifeline outside the hospital. Take your partner to your midwifery interview. Ask the midwife if she can place an IV in their arm, in the midst of conversation. Not only will your partner likely have much easier veins to access because they aren't currently bleeding out, but the scenario is not currently life-threatening. If she proves too intimidated, unprepared, or unimpressed with your request, is she really the one you want by your side in an emergency, too far away from emergency personnel (who don't care anti-hemorrhagic medications anyway) or a hospital capable of managing your emergency in a timely manner?

Don't think it's beyond me as a midwife to set up my own assistants within the clinic either. On more than one occasion, amidst a busy day, I would drop a doll on the floor and yell out that my baby isn't breathing. My staff knew this was test - they had to perform all the necessary skills for saving that child, including running for all necessary equipment, right there in front of all our awaiting clients. Was that intimidating? Hell, yes! Do you know what's worse? Doing the same with a real child who is dependent on you for their next breath, while parents watch in completely horror, and emergency crew enter the home, often threatening and hostile. If I were super ornery and interviewing a midwife myself, I may even bring my own baby doll and drop it in front of her, abruptly pulling out my stopwatch and awaiting her response.

It isn't just these clinical drills which are important for developing a midwife's expertise, but also the debriefing opportunities. Once in my own practice, we had a neonate born without the capacity to breath. We later realized she had suffered carbon monoxide poisoning for which she could not overcome, but in the moment, we offered her a full resuscitation, complete with intubation and an umbilical line. During the resuscitation, I was performing the intubation, while the second nurse-midwife was evaluating my placement, and the registered nurse was providing chest compressions. The midwife shared that she was unable to hear sufficient lung sounds, so we immediately pulled the intubation tube and returned to use of our T-piece resuscitator. As the paramedics arrived, they assisted in the intubation and were able to assure placement was correct, but we struggled to find necessary equipment on subsequent attempts. As we replayed this scenario following the event, and debriefed our experience - all while being recorded - we realized that I was throwing equipment behind me which made it difficult for the support staff to locate. I didn't realize until that moment that in my mind, I wanted a clean working environment. I had no previous awareness even that I was doing this. Recording our responses and debriefing was paramount to improving our skills.

Forty percent of women who hemorrhage following birth had no risk factors. Midwives working in either birth centers or the home care primarily for low risk women and because they generally have a hands off practice, they see fewer obstetrical emergencies. This means their clinical skills are less often utilized, and their familiarity with these scenarios aren't as keen. It is my opinion that midwives working within these settings should be the best of the best and train rigorously in proper management of emergency scenarios, because they are somewhat disadvantaged when these scenarios present. Keep in mind, the beauty in homebirth and birth center birth is that the approach to care in itself greatly reduces these emergencies, which is why parents choose this option in the first place.

Active Management of Third Stage

This is potentially one of the tougher considerations with homebirth clientele, as active management of the third stage of labor has demonstrated to be the single most important approach to preventing postpartum hemorrhage, but opposes all that seems sacred about homebirth - trust the physiologic process and only intervene when medically appropriate. The administration of oxytocin seems to be the key component of the three recommendations - oxytocin administration, uterine massage, and cord traction. The World Health Organization, the College of Obstetrics and Gynecology, the American Academy of Family Physicians, and AWOHNN all recommend oxytocin administration after all births, but as I am aware, this is not the standard of care in out-of-hospital births. These organizations do respect that women without risk factors having a physiologic birth (spontaneous onset of labor, without epidural analgesia or other medications) who make an informed choice to forgo prophylactic oxytocin can be supported in their decision, which begs the question, is hospital birth really the safest place to birth one's child if their normal, routine management increases postpartum hemorrhage to the point that routine intervention to protect from fatal hemorrhage is now standard?

Midwifery Care & Obstetrician Perception of Such Care

Every midwife I know can share with you a story of when they offered excellent care yet were still treated hostile by their physician or hospital-based colleagues for no other reason than their practice environment. Two quick examples, followed by one specific to hemorrhage, I think well articulate this point. One of the most skilled nurse-midwives I have had the pleasure of working with diagnosed a client with breast cancer early in her pregnancy. Funny enough, this client had been referred for diagnostic testing twice before and the radiologist was confident there was no pathology, but this midwife intuitively felt differently and demanded more thorough evaluation, which proved just how strong her experience had developed her gut senses. Once her cancer was realized, the radiologist determined this midwife to no longer be qualified to care for her client, so took it upon himself to violate HIPAA and notify an obstetrician who had never met this client. They contacted her and informed her of this horrifying diagnosis and due to her progressing pregnancy, she required termination the next morning. Once the midwife followed up on the case, learning of the privacy breech and this obstetrician's treatment plan, she drove to the client's home and discussed alternative options with the client. Having organized a new care team, which included the midwife, this mother was able to carry her pregnancy to a point that allowed her to deliver a viable child and ultimately, undergo treatment for her cancer - saving both mother and child. It is disgusting beyond belief that this radiologist, and subsequently, this obstetrician lacked any respect for the relationship between this midwife and client, compromising and undermining her care.

This isn't an isolated event however, and after more than a decade in practice, I would argue this is more the norm, than the exception. A client within my own practice was met by a nurse-midwife employed by myself who recognized a significant heart murmur, ordered an echo and referred to cardiology. Their immediate reaction was to recommend urgent cardiac surgery and to involve an obstetrician, again, who had never been introduced to this client. They contacted her directly without first contacting our midwifery team, later stating she was outside our expertise so our services were no longer necessarily. Ironically, this client had already birthed two children in the same hospital system that hijacked her care, yet they missed this congenital cardiac finding through both previous pregnancies? While a team was necessary to care for this client, she was cognizant enough of the advantages of having a midwife to advocate and counsel her through the duration of her pregnancy, including her postpartum care when which her surgery was ultimately determined most appropriate.

The hemorrhage case for which I had referred though, was a client who birthed quite uneventfully at home with myself and two other nurse-midwives in attendance. After managing her care for several hours postpartum and tucking mom and child into bed, we received a call from her mother that she had gotten up to the bathroom and had passed out. Syncope in itself isn't entirely pathologic following birth, as exhaustion alone can create this scenario. However, the mother felt she had bled a little more than she was comfortable, so without much worry, I asked the closest midwife to return to her home to evaluate. She didn't demonstrate an ominous hemorrhage, but more so a rather steady heavier flow than we were comfortable leaving unobserved. A transfer to the hospital occurred several hours postpartum, where upon she continued this heavy flow requiring several units of blood over the next two days. The third day she was observed and finally sent home. Never was this hemorrhage investigated. No further questions were asked. No additional labs were obtained. It was assumed to be related to poor midwifery management, yet as any appropriate clinician would do, I ordered a battery of tests the obstetrician stated were unnecessary and a previously unrecognized blood clotting disease was realized. Into future pregnancies, this awareness became critical in preserving the life of both mother and child.

Post-Traumatic Stress Disorder & Birth Trauma

As mentioned, I suffered post-traumatic stress disorder myself, as the clinician, after managing a client's hemorrhage. This happens to both clients and their providers, and is important to recognize and management appropriately. Even when the hemorrhage is appropriately managed, either may endure trauma. Debriefing is vital and in our own practice, this was a requirement prior to leaving the birthing scenario, which we found decreased resignation from the practice due to feelings of doubt and overwhelm. We also quite regularly covered the expense of EMDR therapy for staff enduring traumatic birthing events. This is what helped me move past the traumatic hemorrhage I attended.

These traumas are exceedingly important to address even if they maybe feel normal and common, because chronic stress in itself can create a post-traumatic response for the brain, so therapy is essential. Talk therapy doesn't seem to always be sufficient though, which is why being familiar with a skilled EMDR therapist is vital, in my opinion.

While care teams do not have the freedom to discuss these events with friends and family for support, midwifery practices should foster a culture of open communication so concerns and questions can be immediately addressed. Certainly most healthcare practitioners can tell you of unfortunate working environments where they were told not to talk about the details, and if they did with anyone at anytime, they would be terminated. This worsens trauma and completely halts efforts for future improvement.

Outcomes should be monitored and processes implemented for improvement, that allow for suggestions from the entire team. One of my newest and most inexperienced nurses identified when our practice first implemented the T-piece resuscitator in the home setting, the first in the country to do so, that it was critical to obtaining a secure airway to first wipe the face of the newborn, particularly when born in water. It was a nurse who taught highly skilled surgeons to wash their hands prior to diving into the depths of the wounded saving generations of soldiers.

In an ideal world, both the homebirth team or birth center staff would debrief with the hospital staff so transfer management could be optimized. However, generally speaking and in my experience, hospital teams to fear liability with candid discussion of events occur when birth transfers from home to hospital. There certainly are midwives across the country however, who have established more respectful relationships with an eye on improving care, who have successfully implemented this strategy. The added benefit is that midwives can share more about their great outcomes, as hospital teams only see those challenging cases which weren't successful at home and have a skewed perspective on resources and skill set. If clients want to support their midwife, in my opinion, I believe it would be very advantageous to update hospitals within the community of successful birth outcomes, as well as any consulting doctors, including radiology, ultrasonographers, and potentially even pharmacies. This way their understanding of out-of-hospital birth isn't just those crazy stories they hear, but also all the many which go exceedingly well. This would ultimately improve transfer arrangements, improve outcomes for mothers and babies who do necessitate hospital transfer and timely medical management.

Main, E. K., Goffman, D., Scavone, B. M., Low, L, K., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., & Levy, B. S. (2015). National partnership for maternal safety: Consensus bundle on obstetric hemorrhage. Society for Obstetric Anesthesia & Perinatology, 121(1), 142-148.


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