MIDWIVES...reasonable handling of PPH? (better info added 5/27) - Page 2

[caedmyn]

bump for added info

[MsBlack]

Originally Posted by caedmyn

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.

I find this fairly concerning....I mean, sounds like a pretty normal situation at first--but once the bleeding occurred, why not use herbs/homeopathics in this situation? Do you know if baby was nursing, or if fundal massage or nipple stim was done?

And if pitocin is used to bring up b/p, I've never heard that before. Pit is an artificial form of the hormone oxytocin--it stimulates uterine contrax to cause uterus to shrink down and stop bleeding.

I don't know--it's hard to tell from here. I'm left with more questions than answers--and wondering if this mw really knows enough about pp bleeds, how to stop them and how to promote mom's fast recovery afterwards. Again, I don't know--but I'm concerned.

I will say that I've seen a few bleeds that were definitely 'borderline' as far as considering transport goes--we stayed home. And I knew that recovery would likely take more time than usual pp recovery--told the family as much, gave them a specific list of do's and don'ts, with the general admonition, oft repeated in the first days/weeks "REST! Pay attention to how you feel, don't push yourself at all." Here is an incomplete list:

Do: drink drink drink plenty of clear fluids, get plenty of calories including high protein, double your multivitamin (maybe), rest rest rest as much as needed and stay mostly in bed for at least a few days. Resume life only very slowly after that. Do listen to your body very attentively
Don't: get out of bed or even sit up for more than few minutes in the first couple days (so--crawl to the bathroom or pee in a bucket at the side of the bed, use a bedpan--whatever is easiest), don't do ANY chores or be in charge of other kids, don't let visitors stay in your company more than a few minutes at a time (visitors should be helping out, not tiring you out)....

Anyway, if mom was still getting dizzy after only 5min of standing, one week later, I'd say she either didn't know how to promote her fastest recovery, or wasn't compliant. Yes, it would take more than a week to fully recover from such a bleed-but at 1wk pp, for families who know what to do/not do, and have pretty much complied with that, standing for 5min has never been a problem in my practice.

Again, though, this is about more questions, no real answers for you.

[caedmyn]

Originally Posted by MsBlack

I find this fairly concerning....I mean, sounds like a pretty normal situation at first--but once the bleeding occurred, why not use herbs/homeopathics in this situation? Do you know if baby was nursing, or if fundal massage or nipple stim was done?

And if pitocin is used to bring up b/p, I've never heard that before. Pit is an artificial form of the hormone oxytocin--it stimulates uterine contrax to cause uterus to shrink down and stop bleeding.

I don't know--it's hard to tell from here. I'm left with more questions than answers--and wondering if this mw really knows enough about pp bleeds, how to stop them and how to promote mom's fast recovery afterwards. Again, I don't know--but I'm concerned.

I will say that I've seen a few bleeds that were definitely 'borderline' as far as considering transport goes--we stayed home. And I knew that recovery would likely take more time than usual pp recovery--told the family as much, gave them a specific list of do's and don'ts, with the general admonition, oft repeated in the first days/weeks "REST! Pay attention to how you feel, don't push yourself at all." Here is an incomplete list:

Do: drink drink drink plenty of clear fluids, get plenty of calories including high protein, double your multivitamin (maybe), rest rest rest as much as needed and stay mostly in bed for at least a few days. Resume life only very slowly after that. Do listen to your body very attentively
Don't: get out of bed or even sit up for more than few minutes in the first couple days (so--crawl to the bathroom or pee in a bucket at the side of the bed, use a bedpan--whatever is easiest), don't do ANY chores or be in charge of other kids, don't let visitors stay in your company more than a few minutes at a time (visitors should be helping out, not tiring you out)....

Anyway, if mom was still getting dizzy after only 5min of standing, one week later, I'd say she either didn't know how to promote her fastest recovery, or wasn't compliant. Yes, it would take more than a week to fully recover from such a bleed-but at 1wk pp, for families who know what to do/not do, and have pretty much complied with that, standing for 5min has never been a problem in my practice.

Again, though, this is about more questions, no real answers for you.

Baby was nursing and fundal massage was done. I don't know why pit wasn't given sooner, especially as midwife told me when I initially interviewed her that she likes to just give pit right away (or at least not mess with herbs or homeopathics) if she thinks someone is bleeding too much.

Doula told me that she thought midwife looked on the internet to see if a certain pulse rate or strong pulse rate combined with the low blood pressure was safe. Now I don't know if she actually did or not, but it seems really odd to me if she did do that. She's been a midwife for 20+ years and delivered 800+ babies, so certainly she *should* know what she's doing in the case of a PPH.

I don't think mom was dizzy after standing for 5 minutes a week later, just exhausted. And who knows how much else she had already done that day, KWIM? I don't know all the instructions mom was given but know she was told to take extra iron and she didn't do that consistently, and she was told to stay home & rest for 2 weeks and she didn't do that either. Knowing her she probably didn't pay too much attention to any of the instructions. But she did have family staying with her and taking care of her kids & house for her.

IDK there are just lots of little things that tell me I should go with a different midwife. Several little issues with faulty equipment (tried to find my baby's heartbeat at 10.5 weeks with Doppler that had been dropped or something and was extremely static-y, then tried to use same Doppler again for HB at 13 weeks before finally getting a new one out...and she has a midwifery supply store so it's not like she didn't have other Dopplers available). Her hanging scale didn't weigh my friend's baby accurately (said 8.8 lbs at birth and 10 lbs at one week, but baby was weighed on a digital scale at doctor's office at 2.5 weeks and weighed 9.9 lbs and there's no way she lost weight in between). Also she has some sort of instrument or chart or something to check hemoglobin levels, and mom said at her 4 week PP visit midwife said something about not being sure what color it was but she thought it was 20 and mom said she didn't think she was reading it right b/c her hemoglobin levels have never been that high in her life. The scale thing doesn't really concern me...I don't know how you calibrate them or how hard it is for them to get off but it seems like something that might happen without you knowing it. But the other things do concern me.

Another thing that concerns me is that the midwife said she doesn't usually check messages on her cell b/c she can't figure it out (this after I left a message wanting to change an appt. time that was never returned). Said she prefers to be called at home since she's usually there, and when she's not she has cell phone right with her. Well we all know cell phones don't always have good reception in every location and sometimes you just miss a call (taking a shower??) so that concerns me too.

And maybe this is out of line for me, but apparently I missed an appointment last week (though I am about 90% certain she wrote it on the wrong day in her book, she almost did that this time until I pointed out that it was the wrong date) and she didn't call or anything. I would have expected a call checking to make sure everything was ok...I'm pretty certain my other two midwives would have done that. But maybe I'm expecting too much there?

[turnquia]

Either way Caemyn... you soud completely uncomfortable with this midwife... looks like you should switch

[triscuitsmom]

Originally Posted by turnquia

Either way Caemyn... you soud completely uncomfortable with this midwife... looks like you should switch

Agreed. I don't think it matters why. You clearly don't trust her and that matters at a birth. Whether the problems would be problems for someone else or not doesn't matter. They are to you. Listen to that.

[caedmyn]

Originally Posted by triscuitsmom

Agreed. I don't think it matters why. You clearly don't trust her and that matters at a birth. Whether the problems would be problems for someone else or not doesn't matter. They are to you. Listen to that.

It does kind of matter because I have to convince DH, and he's not going to let me switch for no good reason (not being comfortable with her won't be a good reason in his book).

[Annoia]

Originally Posted by caedmyn

(not being comfortable with her won't be a good reason in his book).

IMNSHO, this is an especially important reason if you are going for a homebirth. You really, really, need to be comfortable with your HB MW.

If switching isn't an option, then talking to the MW and expressing your concerns *until you feel your concerns have been addressed* is vital.

[caedmyn]

Originally Posted by Annoia

IMNSHO, this is an especially important reason if you are going for a homebirth. You really, really, need to be comfortable with your HB MW.

If switching isn't an option, then talking to the MW and expressing your concerns *until you feel your concerns have been addressed* is vital.

It's an important reason to me, but not to him. I'll talk with him and lay out all my concerns and see what he says. He may or may not agree to switch, but if he does, I'd like him to actually be on board with it (as opposed to just giving in), otherwise I'll be hearing about it for the rest of the pregnancy, if not the next several years besides!

I'm going to talk to the other midwife I like and see what her fee would be if I were to switch at around 28 weeks, once all the lab work is done. If at that point there's only a few hundred dollars difference between the two I think DH will be less reluctant to switch.

[mwherbs]

I want to encourage you to do what is most fitting for you- regardless of external proofs- why are you having a home birth if your comfort and safety are not even in the equation? can your husband be supportive of your choices? very often I find my husband misses many subtle cues that I pick up on- doesn't mean they don't exist I just have different perceptions - if the birth goes easy it doesn't really matter much who is there and if you feel that you don't trust her judgment IF something needs to be taken care of that is enough-period-- your buffer/perception of safety is not there
you see I could go on to say I have worked with midwives who have had dopplers that work ok for births but the crackling interferes with early listening- and it has taken many months for them to buy a replacement- even at the best of times you cannot always hear at 10.5 weeks and I realize the NOW standards are to hear the baby the first minute you can but I started with a fetoscope and still use it sometimes on women who have that preference and we don't hear a baby for the first time until 16 weeks or even later. and lets see to talk about evidence based care- there is supportive evidence for the use of pitocin for PREVENTION of postpartum hemorrhage, but the evidence is not there for the TREATMENT of postpartum hemorrhage, and that is because once you have a hemorrhage it can be more complex than just causing a contraction - lets say that the uterus is fairly well contracted but you still have bleeding well pit really would not be a go-to treatment KWIM because the action it has is to contract the uterus-but it doesn't always work- if the oxytocin receptors are all full or because it may be a lower segment bleed, lets say the placenta wasn't marginal but was on the lower segment then even with good contractions and a tight fundus you could have more bleeding- a fuller bladder would contribute- shares a wall with the lower segment and can keep it fluffed out- but if you cath a mom then you are risking infection... quite a dance to work out and make choices over, there are some other things like methergin or a combo of methergin ( methergin tends to contract the lower segment more) and oxytocin which can have a BP raising effect or the newer choice of misoprostol (this would produce more receptors)
but none of these details really hinge on your decision- you need to feel comfortable with who you have as a provider and you are not- If you cannot work this out with her ASAP change providers if possible- regardless I would recommend you give her some feed back about your concerns-send it in a letter/note
take care

-----
you know I wanted to add that I would hate to have a client who stresses over the details of my care of her or others for weeks and not say a thing to me. What could I say or do that would open this conversation so you would be comfortable talking to me about this?

[nashvillemidwife]

Originally Posted by mwherbs

you know I wanted to add that I would hate to have a client who stresses over the details of my care of her or others for weeks and not say a thing to me.

YES. The details you provide don't concern me, but if I was your midwife I would be very, very concerned about our relationship. The trust between you and your midwife is a two way street, and you've run into a road block. It doesn't matter which way the block is facing.

[caedmyn]

Originally Posted by nashvillemidwife

YES. The details you provide don't concern me, but if I was your midwife I would be very, very concerned about our relationship. The trust between you and your midwife is a two way street, and you've run into a road block. It doesn't matter which way the block is facing.

Not really sure what I would do or say at this point. Bottom line is I don't trust her and that's not going to change. DH wanted me to call and ask why she gave pitocin to raise blood pressure as she said if bleeding had already stopped. I emailed her on Saturday to ask, didn't hear back by late Tues. afternoon (email is supposed to be a good way to contact her and the only way to communicate with her while she's out of the country doing births which she will be later this month so that's another issue but it's possible that she truly didn't get it) so I called her. She said she didn't get my email and I asked her my question. She told me that about an hour after birth bleeding was at normal levels so she took a nap. Mom was supposed to tell her if she got up but she got up to pee without telling her (supported by mom's sis and doula). Midwife wakes up out of "deep sleep" to find mom standing and feeling very faint so they get her on the floor and midwife said she gave her pitocin b/c she didn't know how much blood she'd lost in the meantime (while midwife was sleeping). Said mom's bp was 40/20 at that point. Also said mom's bp last time it was checked before that incident was 110/40 which seems odd (and midwife specifically told me she was looking at mom's chart while she was telling me this so it's not like she misremembered or something). I questioned her on the details several times to make sure I understood what she was saying.

So talked to my friend after this and asked about it, and she told me the midwife didn't take a nap until about 3 hours after birth when everyone there slept, and midwife was right there and TOLD her to get up and go pee! Which is the same information I had from the doula when I talked to her several weeks ago. So the midwife flat out lied to me. It seems quite clear to me that either she knows she mishandled this and is trying to cover up, or she's defensive about being questioned about her handling of it and is trying to put blame on others to take any pressure off herself.

I don't have a problem writing her a letter and saying that I don't feel comfortable with her handling of my friend's situation nor her integrity as a person since she lied to me. And also that I have seen a lot of little things that make me feel that she is sloppy/slip-shod in the way she handles things in general. (All worded a little more nicely of course.) But we will be unhiring her and looking for someone else. I think at this point I'd be more comfortable UC'ing in a hotel a few minutes from the hospital (as we live 25 minutes away) than I would be having her attend my birth.