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PPH - what to do at a home birth?

Last post 12-08-2011 12:09 PM by marlenecpm. 6 replies.
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  • 11-09-2011 9:53 AM

    • newbe
    • Top 500 Contributor
    • Joined on 11-09-2011
    • Posts 4

    PPH - what to do at a home birth?

    Hello! I'm a new midwife (about a year now) and I work in a hospital. I had a case and was wondering what would you do if this happened at a homebirth.  The women was having her 7th child, (no history of cesarians) was induced b/c of post date and non reasurring heart rate for fetus, and PIH in the last week. Active stage of labor was an hour. After baby came out screaming, 2 minutes after (cord still attached) PPH started. Placenta did not seperate from the uterus wall. (I didn't give Pitocin b/c we usually give only after placenta in delivered where i work and i thought she may need lesis/revisio.) couldn't give methergine b/c blood pressure was high 154/94. I called the doctor, urine catheter (only about 200 cc of urine) perinieum was great.  When the doctor came,4 minutes after birth, she tried getting the placenta out...10 minutes after birth placenta came out. did a revisio but uterus was clean.  PPH was about 1000 cc.  babys wieght is 3,400 kilo. mother and baby are fine. once placenta came out, no more PPH.  But the big question is, what would you do at a home birth??  

    thank you for answering!

  • 11-09-2011 6:30 PM In reply to

    • midwifea
    • Top 10 Contributor
    • Joined on 02-12-2009
    • Kailua Kona, HI
    • Posts 475

    Re: PPH - what to do at a home birth?

    Newbe,

    While I can't tell you exactly how I would've handled that birth at home because that birth did happen in a hospital, I can give you a run down about how that 'scenario' might play out at home. Does that make sense?

    Grand-multiparous woman gives birth spontaneously and rather quickly (let's forgo the induction, PIH and postdates (?) because you didn't give specifics about any of those and they may have contributed to the PPH and most definitely would have been handled differently at home)

    Baby is term and has great apgars, cord is still attached, baby and mother are skin to skin. perineum is intact  and there is abundant bleeding at 2 minutes pp. sourced from the uterus.  Attendants immediately put mother and babe in a reclined position, if not there already.  Mama would be asked to tell her uterus thank you and to stop bleeding.  Fluids would be given orally and constantly. One attendant helps mama to initiate breastfeeding if babe is not already doing so.  If baby does not feed, nipple stim would begin by same attendant or by papa, 1st dose of Yunnan Baiyao would have been given immediately at note of blood. Assessment of fundus, placental adherence and contraction activity would already been noted.  Stimulation of contractions by nipple stim,  herbs, fundal pressure, abdominal uterine compression and applied cord traction to release placenta would be next.  Angelica and tinctures for bleeding would be administered simultaneously.  2nd dose of Yunnan administered by 10 minutes after 1st.  Pitocin IM if available and there is no reduction in blood flow. If still no placenta at 10 minutes pp and blood loss is past 500 cc,, give oxygen if available, attempt to remove placenta manually, evaluating mama for shock and toleration of blood loss. Bi manual compression if called for, If all attempts fail call for help.  If birth of placenta is successful and blood loss is considerable but tolerated start regenerating therapies, ie placenta, chlorophyll, fluid volume replacements etc.etc. encapsulating placenta and administering it as a pp medicine would be very helpful as would eating the same raw.

    I think I have covered a lot of options, off the top of my head, any other HB midwives have things to add?

    Blessings,
    April
    moderator

    "The Voice

    There is a voice inside of you
    That whispers all day long,
    "I feel this is right for me,
    I know that this is wrong."
    No teacher, preacher, parent, friend
    Or wise man can decide
    What's right for you--just listen to
    The voice that speaks inside."
    — Shel Silverstein
  • 11-11-2011 10:25 AM In reply to

    Re: PPH - what to do at a home birth?

     Since I practiced as an L&D RN for 10 years before becoming a home birth midwife (12 years ago), I'm more comfortable with medicines rather than herbs.  The worst hemorrhage I've had in my 12 years occurred at about 2 years in practice.  Almost immediately following the birth, the flood gates opened.  I was without an assistant.  I immediately gave pitocin 20 U IM.  I cut the umbilical cord and handed baby to Dad.  The flooding continued as I drew up methergine to give IM.  This wasn't helping and the placenta was not ready to come.  I manually removed the placenta which took me almost a minute to detach and remove.  Then for about a minute I used bimanual compression until the uterus firmed up.   By this time I estimated a 2,000 cc blood loss.  It sounds as if your scenario was not quite as dramatic.  There are fast hemorrhages and slow steady hemorrhages. The only other hemorrhage I had with the placenta still not delivered was a slow, steady kind.  By the time I had the patient's permission to do a manual removal she had slowly and steadily lost approximately 1,000 cc over the course of approximately 45 minutes.  During this situation I started with the 10 U pit, followed later with the methergine and after the delivery of the placenta, started an IV to replace some volume.  It just seems if the placenta is inside and there's problematic bleeding, you just have to get the placenta out using whatever means you have.  It sounds like from your post you don't practice in the US.  Are you not permitted to manually remove the placenta--is that why you called the doctor in? Pit IM usually works for me and I take care of a lot of gravida 7's, 8's, etc.  I agree with April that induction probably played a part with your case.  I'm amazed at how little bleeding happens with my women at home compared to what I used to see during the average birth in the hospital.  I don't think the average person realizes how competently a PPH can be handled at home. 

  • 11-11-2011 11:01 AM In reply to

    • midwifea
    • Top 10 Contributor
    • Joined on 02-12-2009
    • Kailua Kona, HI
    • Posts 475

    Re: PPH - what to do at a home birth?

    I agree with Joy that first and foremeost thought and action is to birth the placenta in situations like this.  Manual removal is not fun for anyone but it needs to be done at times.

    Blessings,
    April
    moderator

    "The Voice

    There is a voice inside of you
    That whispers all day long,
    "I feel this is right for me,
    I know that this is wrong."
    No teacher, preacher, parent, friend
    Or wise man can decide
    What's right for you--just listen to
    The voice that speaks inside."
    — Shel Silverstein
  • 11-13-2011 4:34 AM In reply to

    • newbe
    • Top 500 Contributor
    • Joined on 11-09-2011
    • Posts 4

    Re: PPH - what to do at a home birth?

     hi! thanks for everyones replies! they were helpful. One question- we learned not to give medicines like pitocin or methergine when we think there might be a need for manual expulsion of the placenta b/c then the cervix is closed and its much harder to do the manual expulsion and can cause more complications afterwards (more PPH after you force the cervix to open again). I've seen maual expulsions done a few times after pitocin was given and it was fine. i've never did a manual expulsion of the placenta (where i live, midwives aren't trained to do that. only doctors perform that. there are a few widmives that do home births here but thats only legal after having 5 years experiance in a hospital etc etc but they also don't do manual expulsions.)

    in short, if no one is there to perform manual expulsion, should i give the pitocin before the placenta comes out? or should i massage the uterus (hand on stomach massage) to get it to contract? I learned that its not good to do both those things, but if its PPH, i don't know what else to do (besides catheter of bladder, IV liquids, oxygen)

    thanks so much for your help!

  • 11-17-2011 7:42 PM In reply to

    • Aubre
    • Top 25 Contributor
    • Joined on 02-14-2009
    • Posts 75

    Re: PPH - what to do at a home birth?

     Greetings. This is a great discussion and thanks for initiating it! 

    My very first thought after reading the original post was "she would not be a candidate for a homebirth", with all the complicating factors that you listed, I personally would not feel comfortable with out of hospiatal birth for this Mama.  All the listed conditions, especially added up together, make this Mama high risk and greatly increase her risk for PPH.  (Her gravidity status, by the way, does not bother me, and that alone would not cause me to "risk" her out) 

    All that being said, the worst PPH I have managed (2500cc) happened in a 100% normal, low risk healthy, primiparous Mama in an out of hospital setting.  In my practice, we work with herbs, homeopathics and alternative modalities very frequently.  However, in the face of signifigant hemmorhage, I will not hesitate to use pharmeceuticals as my first line.  In my particular situation, the Mama had had a completely normal course of labor followed by a beautiful physiological second stage and birthed a healthy baby girl.  At approx 20 min PP, before the birth of the placenta and with an actively latched and suckling baby, it was as if a hose was turned on.  My assistants and I did several things at once...I completed a manual removal of her placenta, oxytocics were administered, an IV was started, O2 applied and a urinary catheter was placed.  Despite all these interventions the bleeding continued and I preformed bi-manual compression...all the way to the hospital, in the ambualnce...we were transferred to the gurney together.  Thankfully, she recovered well and quickly.  Those of us who attend birth, must be prepared to intervene quickly and approriately on the rare occasion it is warranted.  One of my collegues explains it to families as, "I know a lot of things and tricks, the best births are when I do not need to use them!"  As guradians of birth, we must be just that, guardians and always watching with a critical eye.

    On the subject of oxytocics before the birth of the placenta; the argument that they will "clamp down the cervix" has been around for a long time.  It has never been documented or "proven" in the literature or research.  After the birth of the babe, the cervix will close up somewhat on its own, as there is no longer a fetal head pushing down on it....

    Again, great discussion and I can't wait to read more insights!

    Aubre Tompkins, CNM
    Wishing you Shade and Sweetwater
    http://www.midwifeyearone.blogspot.com
  • 12-08-2011 12:09 PM In reply to

    Re: PPH - what to do at a home birth?

    1st off, this  scenario is very unlikely to  happen at one of my homebirths, (not that it absolutely couldn't, just very unlikely) One of the 1st things I look at with new clients is their diet, & as you know, most PIH is diet related. If diet counseling didn't correct the PIH, I would probably risk her out for a homebirth, But I have yet to get a client who didn't respond well to diet changes.  

    2nd, I would not  be inducing at home! Artificially produced ctx can be so much more forceful than natural ones, it is much too dangerous to do at home, So if she wanted/needed to be induced, this is another reason she would  be risked out for homebirth.

    3rd, non-reassuring FHT's  are still anothher reason to transport. & they are much more common w induced labors, so if they were not  reassuring before labor, that woulld be another reason to not induce, unless done with just  niipple stim! I'm guessing, if her diet were better none of these things would  have had to happen.  However, I do see a pph once in a while. 

    So, if I see more than 500cc blood before placenta is out, I woulld 1st give Angelica, SL. Then depending on the  quality of the  blood & condition of uterus I  would give other SL herbs. Also get baby (or dad!) to  breast  for nipple stim. Then I would go up  & manually remove the  placenta. & do bimanual  compression until it stopped or squad arrived, Emptying the bladder is also  a concideration, though it didn't look like the  cause in your case. Once the placenta was out, I would slice off a small chunk and place in the bucchal cavity. I have never known that to fail... yet, but I never say "never" or "always" as there is an exception to every rule.

     

     

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