Severe (?) PPH after previous two births - should they have a third?

[elisheva]

A friend of mine is considering having a third child but is concerned about some health issues she experienced in her previous two pregnancies/births. She doesn't know about MDC so I told her I'd ask for her. She has an appt tomorrow with her dr to discuss a possible third pregnancy.

Issue #1 Varicose veins (including vaginal :( - she's been told there's nothing to do but look into surgery after she's done having children. I have also read this. True? Anything else that can help?

Issue #2 PPH - she had hospital vaginal births for both (no induction). With the first she had an epidural that didn't take and used some gas. She bled so badly after the birth that they started her on an IV of pitocin and had to keep it on for two days. With her second, she only used gas and she again had really bad bleeding after. They put her on a pitocin IV again and tried to turn it off after two days but within the hour her bleeding had ramped up again and they had to go a third day with the pit. Is there anything she can do to avoid another PPH? 

Thanks!

[MeepyCat]

I am not a medical professional.  I have a lot of opinions anyway.

The varicose veins - yup, that's all there is.  My understanding is that they're ugly, but not harmful in and of themselves (although they may be symptoms of other problems). 

Most hemorrhages can be resolved within a short time after delivery of the placenta, so your friend's post partum bleeding is very far out of the ordinary.  If I were her, I would want to discuss whether there had been an implantation problem in either case, and whether she has any issues with blood clotting.  She should also discuss third stage management - would it be appropriate to administer pitocin for delivery of the placenta, before hemorrhage starts?  Did her hemorrhage hold off until that point, or did it start earlier? 

I'd also wonder whether the gas (nitrous oxide) might have had an effect on the bleeding.  The most common side effect of nitrous oxide is hypoxia, which causes vasoconstriction (blood vessels constrict) in the lungs, and vasodilation (blood vessels open wider) everywhere else.  Did the choice of anesthetic potentially affect her bleeding?  My bias is in favor of epidural anesthesia over other anesthesia in labor.   I believe it is the safest and most effective of the pharmacological options.  Laughing gas in particular is problematic - during labor, your body is working very hard and needs oxygen.  When you inhale nitrous oxide, you're reducing the amount of oxygen you take in. 

Another thing she might think about is elective c-section.  I know this is not a popular idea here, but I think she should discuss it with her doctor anyway:  What do they think caused the hemorrhage, and would surgery allow her to sidestep that problem?  Would surgical recovery be easier on her than days of pitocin?

[Ldavis24]

OP maybe you know this and maybe you don't but did she have to have a transfusion at all? Bleeding for that many days I would think she'd need something to boost her BP? I am curious, I had a PPH but nothing like what you described so unforuantely I am not much help in the knowing why it might have happened. I'm sure there are far smarter mamas on here than I, you will probably be able to get some answers but it is always hard to comment when you don't know the full extent of the situation.