MIDWIVES...reasonable handling of PPH? (better info added 5/27)

[caedmyn]

I know there used to be a couple of homebirth midwives who posted here, and since non-birth professionals can't post in that forum anymore, I hope someone is around to answer this.

Background: this will be my 3rd homebirth. We've hired a different midwife with each due to moving out of state between DC1 & DC2, and then my midwife with DC2 moved out of state. There are only a couple of homebirth midwives in my area and I have heard a few rumors that the one I have hired may do some things that are not safe...but the rumors are very vague and I have no way of either comfirming or refuting them. So I guess I am having a little bit of trouble trusting my current midwife. She is a very experienced midwife who has attended several hundred births.

My friend just had her first homebirth with this midwife a few weeks ago. She hemorraged (sp?) after the birth and I am a little concerned about whether it was handled in a safe manner...but I am not a midwife and I am hoping to run this by a midwife or two and get some feedback so I can either hopefully feel a little more confident in my choice of midwife, or consider hiring someone else.

Basic details: uncomplicated waterbirth after about 4 hours of labor and a few pushes (3rd vaginal birth for mom). Mom started hemmoraging after placenta was out. Midwife had her get out of birth tub, nurse baby, and did some uterine massage. Bleeding didn't stop and a shot of pitocin was given somewhere between 45-60 min. after this started. Bleeding did slow to normal levels but mom was very weak and BP was 60/40 for quite a while. Mom was always coherent and pulse was strong. Midwife was very observant and checked pulse & BP quite frequently but didn't seem extremely concerned. (initial details from mom & doula)

ETA: talked to the midwife today and this is what I was told:
Mom's normal blood pressure is around 120/80.
She was still in the birth pool when the placenta came out (easily according to midwife), and after that she started bleeding. When midwife noticed water was getting dark she had her get out. Midwife estimated she lost 2 cups of blood after getting out of water, and of course no way of knowing how much she lost before then. Blood pressure got down to 60/40 and after a while mom was dizzy and seeing stars (midwife's terms). Did not say specifically what she did to control bleeding (but nothing herbal or homeopathic from mom & doula's accounts). Bleeding did stop on its own after a while but midwife wanted mom to use the bathroom and when she got up she felt like she was going to faint, so laid back down. Midwife then gave her a shot of pitocin to get her BP back up (midwife's words). Midwife did say she was quite concerned (midwife, not mom), and that she knew she lost a lot of blood because her hemoglobin afterwards was 8 (I don't know what it was before). She mentioned that mom was very weak still a week later and quite shaky after standing up holding baby for 5 minutes for a PKU. She did also say that she had never transferred for PPH (has attended 800+ births).

I know mom did not request no pitocin or herbs or homeopathics first. She would have relied on midwife's judgment as far as transferring, but she (mom) wasn't overly concerned about the whole thing. She can be kind of laissez faire (is that the right term? I've probably butchered the spelling if it is) about things in general.

[GoBecGo]

I'm not a MW, so these are just my random thoughts (and thus can be ignored!). Well, there are so many factors here to know what was really going on...

Who dx the PPH? Was it a massive loss or a bigger than normal one or a bigger-end-of-normal? How many PPH's has the doula seen - if she works a lot in hospital has she seen many normal 3rd stages (un augmented i mean)? 20 births really isn't many if you consider that PPH only happens in 13-20% of births.

Not seeming "extremely concerned" is definitely part of my MW's job. I want her to be calm and reassuring even if i'm on the point of death!

How did mom recover from the birth? Does she feel substantially weaker than usual after this birth? Does SHE feel the bleed wasn't managed well? How were her bloods afterwards?

You could always meet with the MW in question and talk to her about it - i'm betting she has her own internal protocols about how to deal with PPH's and has sound reasons for dealing with it as she did, but you might get a better feel for that if you ask her outright?

[katelove]

It's really hard to judge when you weren't there and don't have all the info so take this with that in mind...

Besed on what you described I would have been more aggressive.

Getting mother out of the tub was good - you need to be able to see how much blood loss there is and the midwife should have done an examination to see whether the blood was coming from the uterus or a tear. Obviously can't do that in the tub.

Breastfeeding is good.

Rubbing up the uterus is good if it is not well contracted.

45-60 mins seems a long wait to give syntocinon if there was active bleeding all that time. If the bleeding stopped then restarted despite the above measures then that may explain the delay. If there was active bleeding that whole time from a poorly contracted uterus ,IMO, the delay was too great.

A persistent BP of 60/40 is significantly low. I would give IV fluids for that. It is good that the mother was coherent, if she wasn't that would indicate a serious oxygen deficiency and would warrant a t'fer IMO.

The "strong" pulse is ok but more important is the rate. I would think that, with a BP of 60/40 which persisted for some time, then she would have had an increased pulse rate. The combination of low BP and elevated pulse are signs of significant blood loss regardless of how much is actually measured or estimated.

I agree with the PP, ask the midwife how she manages PPH and see what she says. If you're happy with the response then I guess you have to decide whether you think her theory matches her practice based on your friends' stories. If I had a PPH managed as you describe then I would be seriously unimpressed *but* I am also very aware that the recollections of witnesses and patients are often vastly different from what actually happened so I would not want to condemn this midwife out of hand.

[Defenestrator]

The first question I have when reading that story is this -- is it legal for your homebirth midiwife to carry and use pitocin? That long of a delay before giving it is the kind of thing I've seen when working with midwives who are very reluctant to give an illegal drug that might be hard for them to replace (making it precious) or might land them in trouble if there were a transport later. I do know a lot of wonderful midwives who don't ever use pitocin and have fine outcomes, but knowing that they don't have it to fall back on, they are often more aggressive with things like herbs or bimanual compression early on when there is a hemorrhage. Maybe your midwife was not so worried because she knew that she had drugs to fall back on, but at the same time was reluctant to use them?

I think that it is really hard to judge just from one story. Bleeding immediately postpartum is very complex -- there is not only one answer to how to stop it and sometimes, despite everything we do, there will be trickle bleeding for a long time after birth and we have to continue to be vigilant and try to find a solution. There are some things that don't add up about this story, though, like a blood pressure that low without changing the pulse or the well-being of the mom. Hard to know where the inconsistencies are coming from -- the reporting from the midwife about what this mom's status really was, or from the mom's memory of it.

[caedmyn]

It is legal for her to give pitocin. But not legal for her to start IVs. Most of the details came from doula's recollections...I think the blood pressure is the only specific detail that came from mom.

I wouldn't say from what I have heard that it didn't change mom's well being as she mentioned feeling very tired/low energy and feeling very faint when she got up to try to use the bathroom. Doula said she was coherent and she would have been more concerned if she hadn't been. I will have to ask about a specific pulse rate. I will ask whether rate of blood loss was consistent or slowed and sped up.

Mom has low iron levels now and says she gets tired easily...not sure exactly what her iron levels are. She said she didn't feel like she even gave birth the next day (so fine in nether regions) but quite tired. Mom said she thinks her iron levels were low at the time of birth but apparently they were within normal levels when the 28 week bloodwork was done.

I will talk to the midwife but I suspect this is a pretty typical way for her to handle a PPH. That is really my concern with the safety rumors...I do not think *she* thinks she does anything unsafe (she's pretty concerned with keeping her license) but rumors indicated she may do things that are generally considered less-than-safe, like allowing someone to go with water broken for a week before labor started. It doesn't really matter to me if it's her standard practice (well I guess it does if it's not safe), it matters overall whether it's safe.


You know, I wish we had more money and I could just hire the midwife I really wanted...we chose this one (out of 2 choices) because she has more experience (other is apprentice midwife close to being licensed, her CNM mentor would come to birth) and because she's about $800 cheaper and will let DH work off most of her fee.

[HeatherB]

I'm not a MW, either, but agree with the other posters. IME as a birthing mother, I've received pitocin within about 30 minutes for higher-than-optimal bleeding (we also know my uterus tends to be slow to contract), but I was not in or on the verge of PPH. So, the biggest issue for me in the story is the time before pitocin was administered. Were there other herbal/homeopathics being given? I am not opposed to those being tried first, but waiting too long can be dire.

As for the other rumors of going a week with water broken, as long as there are no exams happening, and mama and baby are fine and there's no fever or indication of infection, I have no problem with that. Different breeds of MW will do it differently, but that's not something that would make me want to switch care providers.

Still, if you're not confident and able to fully trust your MW, you would be well served to investigate options for the other one. I think that trust is of utmost importance in a birth! Definitely talk to her about your questions on these issues, and see how you feel after that.

[Jane]

I don't think I have enough information to add anything really useful about PPH. If the mother is quite weak, then she probably wishes to have had more things done to lessen her blood loss.

I'd probably suggest talking to your midwife and let her know that you are would like to talk out a few scenarios with her. Let her know that you are okay with erring on the side of accepting interventions that may not have been neccesary if there's a safety factor for you or your baby. For instance, I think waiting for labor after rupture of membranes is something where you could totally have a different idea of when you'd want a hospital induction. Or, you may want active management of third stage (pitocin injection between baby and placenta). It should be a helpful conversation.

[cileag]

I agree with Apricot. I had many conversations with my midwives about potential scenarios and they knew that I erred on the side of caution and would prefer to receive Pitocin if there were any questions etc. The great thing about midwifery care is that you really get a chance to personalize your care---use it!

[caedmyn]

The thing is, I really am not geared toward erring on the side of caution. I would be comfortable with something like a twin homebirth or breech homebirth with a confident experienced midwife and no complicating issues (not possible in my state anyway). I don't want active management of 3rd stage, but at the same time if there is too much bleeding I don't have a problem with pitocin...I'd rather have it a little sooner than waiting using it absolutely as the last resort. I've had very hands off births and prefer a hands off midwife, but I want to feel that I can trust her to act appropriately if necessary. I don't want to feel that I have to be alert for any non-routine scenario where I might have to ask for/prompt an action on her part, if that makes any sense. I don't want to feel like I'm UC'ing with a midwife there, and that's kind of how I feel ATM.

I guess I will update this if I am able to get some more details about my friend's birth, and after I talk with the midwife again which won't be for a few more weeks.

[turnquia]

Ok... Its hard to know really for sure what happend from 3rd party stories.

Your friend went in with lower than normal iron levels, and most likely lower than normal hemoglobin levels. So it would take a smaller blood loss to create the results you posted above. (The low blood pressure and the fatigue).

however BP that low with a conscious mom who was fine with no pulse changes is most likely from a cuff that is on too loose or too big. If that mom's particular BP tends to run 80/50;s... then 60/40 isn't a HUGE drop. Enough to make you symptomatic.. yes but its not a huge drop.

Also IF your friend's BP was that after standing up its because she was orthostatic from the blood loss, and its a normal response when standing up that your BP drops slightly... it drops more if you are dehydrated (from a long labor and not eating and drinking) or blood loss.

It sounds like your midwife may have handled it fine at the time given what she was presented with. I am a nurse and while your doula may say she has never seen that much blood before... ... blood no matter how little looks like a LOT. I have seen a vial of blood drop on the floor and make a HUGE mess. That is only 5-10 ML of blood.. less than a tablespoon... yet it looks like someone was seriously hurt in the room.

So it sounds reasonable, however I would questions the BP. And why she didn't transfer? Or give the pit sooner. However its hard to say whether or not anything was inappropriate because getting the story from the doula isn't as accurate, nor is from mom when she was tired from having a baby and possibly blood and oxygen deprived.

Hopefully your friend is feeling better, but sounds like either way she was likely to feel tired after the birth, she went in at a disadvantage being anemic already.

[turnquia]

Oh and I wanted to say... it sounds like your clearly uncomfortable with this midwife. Maybe reguardless of what she says to you, maybe finding a new midwife would make you more comfy.

[ShwarmaQueen]

As someone who experienced PPH, I can honestly say that sometimes it just happens with no one being to blame. I would ask the MW for specifics about the situation if you're concerned.

[katelove]

Originally Posted by turnquia

Your friend went in with lower than normal iron levels, and most likely lower than normal hemoglobin levels. So it would take a smaller blood loss to create the results you posted above. (The low blood pressure and the fatigue).

however BP that low with a conscious mom who was fine with no pulse changes is most likely from a cuff that is on too loose or too big. If that mom's particular BP tends to run 80/50;s... then 60/40 isn't a HUGE drop. Enough to make you symptomatic.. yes but its not a huge drop.

Also IF your friend's BP was that after standing up its because she was orthostatic from the blood loss, and its a normal response when standing up that your BP drops slightly... it drops more if you are dehydrated (from a long labor and not eating and drinking) or blood loss.

I have to respectfully disagree with the above. Unless your iron and Hb are critically low (ie low enough to cause a cardiomyopathy!) then a lower iron/Hb will not cause a drop in BP. The BP drop is caused by a loss of volume.

I agree that, if Mum's BP is normally on the lower side then this isn't a huge drop. However, if it causes symptoms then it is too low. We don't know what her pulse rate was and a "strong" pulse doesn't really mean that much in a young person. It's better than "thready" but still doesn't mean much. A BP of 60/40 means a MAP of 53. Renal perfussion requires a MAP of 70 (although, of course, some people can get along quite well in the 60-65 range). I am assuming that this woman was otherwise well and healthy and therefore she should have been able to cope with this type on insult for a short period but, it is still no reason not to treat blood loss agressively IMO. And if she is already dry from a long labour with not enough food or fluids then that is all the more reason to treat as her reserves are lower to begin with.

A BP will naturally drop on standing but a young, healthy person should be able to compensate very quickly. If it was only on standing (and I didn't get that impression from the OP) then, either the midwife took the BP too soon, without waiting for compensation or the mother was not able to compensate which is another sign of hypovolaemia.

OP I totally get what you're saying about wanting the midwife to be able to intervene without your prompting. It is the main reason why I would never choose a UC for myself. I don't want to have to be my own midwife IYKWIM. I want someone I can trust to do that for me. YMMV but I would not be comfortable with a midwife who wasn't able to give IV fluids. That is a pretty basic resus tool to be without.

[caedmyn]

Originally Posted by katelove

I agree that, if Mum's BP is normally on the lower side then this isn't a huge drop. However, if it causes symptoms then it is too low.

Mom told me her blood pressure was normally "perfect" after I said mine tended to be low normally (100/65ish for me) so I assume hers is closer to 120/80 normally or at least higher than mine.

A BP will naturally drop on standing but a young, healthy person should be able to compensate very quickly. If it was only on standing (and I didn't get that impression from the OP) then, either the midwife took the BP too soon, without waiting for compensation or the mother was not able to compensate which is another sign of hypovolaemia.

No blood pressure was resting BP...faintness was upon standing.

YMMV but I would not be comfortable with a midwife who wasn't able to give IV fluids. That is a pretty basic resus tool to be without.

Unfortunately the CPMs in this state are not allowed to start IVs. My previous midwife who came from a different state was willing to do it anyway, but this one isn't, and I wouldn't have that option if I went with the other midwife either (unless the CNM who mentors her would be willing to do it if necessary).

[caedmyn]

Originally Posted by turnquia

Oh and I wanted to say... it sounds like your clearly uncomfortable with this midwife. Maybe reguardless of what she says to you, maybe finding a new midwife would make you more comfy.

You are right, I would be more comfortable with a different midwife. But I am not going to be able to convince DH to switch without a good reason, especially since this one is about $800 cheaper than the other who's still an apprentice.

[MomsAndMiracles]

There really is not enough clinical information here to determine whether or not the situation was handled appropriately. It's not worth picking apart unless we know things like:

Mom's true baseline BP ("perfect" could still be 90/58 etc.)
The estimated blood loss
The fashion in which the bleeding occured (was it fine at first, but a slow trickle continued??? etc)

I wouldn't even further examine this unless you had the stats. It could have been handled perfectly or terribly with the info that you have. I wish I could be of more help : (

Kristen Elliott LM, CPM

[MidwifeErika]

It is really hard to tell from these bits of the story if it was managed correctly or not.

I think it would be wise to bring it up with the midwife if you are concerned. It might be good to hear from her how she likes to manage PPH, what her thought process is, etc.

[GoBecGo]

Originally Posted by caedmyn

You are right, I would be more comfortable with a different midwife. But I am not going to be able to convince DH to switch without a good reason, especially since this one is about $800 cheaper than the other who's still an apprentice.

Feeling like you are UCing with a midwife there IS a good reason. You have to be able to feel comfortable and confident that the midwife in question is looking after you well, otherwise what's the point?

[turnquia]

Originally Posted by katelove

I have to respectfully disagree with the above. Unless your iron and Hb are critically low (ie low enough to cause a cardiomyopathy!) then a lower iron/Hb will not cause a drop in BP. The BP drop is caused by a loss of volume.

I didn't say that her having low iron/hgb would cause her BP to be low.. just that it would take LESS of a blood loss to cause the symptoms because she was lower to start with. If your starting with a hemoglobin of 14 and drop to 12 its a lot of blood loss but not as big of a deal if you start at 8 and drop to 6. You will most certainly be symptomatic a lot faster starting off already low.

[mwherbs]

communicate with the midwife directly about your concerns. You are not going to be able to settle the details of this particular birth but I think you should state your concerns and preferences-

Too little info to really know what all went on, including prenatally mom may have made preference statements like she did not want pitocin or could even be that mom expressed that she did not want to be transferred. who knows this hearsay only informs you to a limited degree, especially from someone who has only been to 20 births lots of details that are not discussed or understood. So if you were this midwife's client and you did have something that is out of typical range but fine with you as a mom in theory and then in practice it was not exactly what you expected in out come but your wishes at the time were honored... I know for sure I have given shots of pit an hour after the birth, not because it was illegal but because of the pattern of bleeding or it took 45 minutes for the placenta to detach(usually out in 5-15 min)- and I have to also say that I rely less on a clock and more on what is happening as a pattern and what is happening at the time, as well as honoring wishes of the parents. I have not found bps to be useful in assessing bloodloss because mom's bodies usually compensate well- more important to me is what is the pulse- what has it been and what is it now- we have hung IVs legal or no (actually undefined in our state) I also know midwives who never or nearly never use pit- they use their hands or herbs - so find out what this midwife does - communication is probably the only way to reach an understanding and to build trust and it may be you need to find another midwife