History of postpartum hemorrhage - would you start labour with a capped IV and agree to active...

[dot1]

Hi all.  Expecting child # 2 this year.  I'm 39.  Had hemorrhage after dd1 - needed very nasty drug called hemabate (?spelling)) to finally stop it after pitocen wasn't doing the job.  It wasn't gushing - just lots of huge clots.  Only ended up with hemoglobin drop of 20 (didn't need transfusion) so in the end it wasn't too severe...but I guess it could have been.  It was an induced labour at 40 weeks due to very high blood pressure plus low amniotic fluid levels....and a very high amount of pitocen (syntocinen) was needed to get labour going - and when it did finally get going, it went fast and furious (thankfully). It's no wonder I hemorrhaged!

My midwife is recommending active management of 3rd stage of labour (placenta delivery - involved shot of pitocen before placenta delivered to help uterus clamp down along with gentle traction of umbilical cord when delivering placenta).  She is also recommending having an IV put in during labour "just in case" (but not have anything going in it...just cap it, tape it over to allow getting in tub, move around, etc.).  At first I was thinking I'd rather just go into labour expecting things will go well, forgo the IV until actually needed.  She would completely support whatever choice I make, but explained that sometimes after a high amount of blood loss, it can be hard to find the vessels (they lose pressure) and make it more challenging to start an IV line (e.g. if emergency transfusion needed, etc.).  She's pro-natural/minimal intervention everything else where possible (delayed cord clamping, kangaroo care, breastfeeding immediately, various positiions, etc.).  As for active management of 3rd stage of labour, the medical research seems to support it as a measure to reduce postpartum hemorrhage...yet there is also some unofficial literature that I've come across suggesting that gentle cord traction is not at all recommended by some midwives (but I can't find any actual evidence in the medical lit to support this).

Just curious what others would do.  Would you go with the capped IV port and active management of 3rd stage of labour?  Why or why not?

.

[Smokering]

In your situation, I'd say those interventions sound reasonable. I've had people digging around to find a vein when I was dehydrated, and it really isn't fun! And active third stage management does seem to be pretty evidence-based (although, I went for physiological third stage with my recent birth... but then, I did lose over a litre of blood!).

[kathrineg]

I've also needed an IV while dehydrated and it took them quite a while to put it in, plus they hit a nerve in my hand which was incredibly painful and caused some minor nerve damage. I would be more than fine with the IV. 

[milomama]

Why did the hemorrhage occur?  I had a hemorrhage after my 1st due to retained pieces of the placenta.  I had active management of the third stage, and think that the traction on the cord may have pulled things away before the whole placenta was ready to go, leaving some pieces behind.  I was quite worried this time about hemorrhage, but both my midwife and my naturopath have told me that there is no reason to think I will hemorrhage again.  In fact my midwife is fully supportive of planning a homebirth this time, and basically leaving the placenta alone.  She told me there are cases where hemorrhage is more likely to repeat...but in my case, she didn't think there was any more risk than anyone else.

In your situation, I would probably ask a few more questions about why they consider me at risk of a repeat hemorrhage.  Maybe on closer inspection of your previous birth, you may find that you aren't at particular risk.  At the same time, I guess having the IV put in and taped over isn't a huge deal, but would make me feel more nervous that people are "expecting" things to go wrong.

[Magali]

For my last birth I was very clear that I did not want an IV port unless there was an emergency.  I went as far as signing a refusal form.  I can't remember why, but I ended up getting a site set up before hard labor started.  And I am glad that I did because I ended up getting an epidural in anticipation of pitocin (which i didn't take after all).  By the time I actually needed the IV, it would have been real hard for me to be still long enough for them to put it in.  I had them take it out right after birth.  So I would get the IV port, because you never know what can happen during labor.  My labor certainly was unpredictable.  And as for the pitocin shot, well I honestly don't feel all the strongly either way, but with your history I would do it.

[lookingforaname]

I had a hep-lock (IV entry point taped down) for #1 because of Group B Strep antibiotics - it's not that big a deal, just a needle entry point (feels like a shot going in) taped on your arm.   #2 was accidentally a UC, and #3, I had agreed to get one, but she was so fast and the hospital so busy that they never got around to putting one in. : )

Anyhow, just to say, given your history, I would think the cost-benefit is worth it.  The pitocin I don't know as much about, but I will say that your midwife sounds like someone who you can trust, and that's who I would go by, over anyone over the internet!  She knows much more about your history and current situation!

[Triniity]

I planned to refuse the i.v. line for #2, but than they talked me into it at admission (it was capped thought) - and my DH did it (a doctor) so it did not freak me out that much. Turned out that I needed it - there was a funny uteral lip thingie disturbing the birth and being a risk for an uterus rupture (I did not understand completely and was kind of busy at the time :) ) and they gave some kind of medication to relax the uterus until the lip thingie thing could be removed by the midwife (whatever she did :) ).

After birth my placenta did not move, so I needed the pitocin I refused in my birthplan - twice. Which was a bit ironical, but I plan to have the same plan this time (only that I have a placenta praevia, therefor I might need to cancel everything - but I plan differently just now! *beingstubborn*).

You just need to decide if you´d be able to stand poking in an emergency (they always get something in somewhere) - that might be really uncomfortable (I had it once done)  - or if you prefer to have the i.v. line from the beginning. I´ll try to go without :)

[dashley111]

I had a PP hemorrhage because of a retained placenta with my first that required a few transfusions.  I lost consciousness, I don't really remember what all was done but my last awake memory was of an OB up to her elbows in my uterus.  When I researched and talked to a few doctors, I found that it is more likely to occur again if it has occurred a first time.  I opted to have the IV in place, and the hospital took extra precautions and had blood not only on hand, but in my room at the time of delivery.

NOTHING went wrong.  I successfully birthed my child and my placenta with no problems at all.  I still don't regret the decision to have the IV, though- because I know that in the case of an emergency even seconds really do make a difference.

[dot1]

Wow - what thoughtful and useful replies!  Thanks all for sharing your stories:)

I had 2 very major risk factors for hemorrhage:  induced labour requiring a very high amount of pitocen relative to what the nurses usually needed...as well as high blood pressure (I think it was averaging around 150-160/95 around birth when I'm normally a 105/70).  I think it's about a 20% chance I'll have high BP again, and who knows if I'll need an induction.  I don't recall off hand what the actual stats are about risk of recurrence of hemorrhage, but I wonder if things would have been different without those 2 major risk factors.  I also had a  fast labour (basically only 2 hours active labour and an hour of pushing).  Neither of my 2 sisters hemorrhaged with their 2 kids each and they all went into labour naturally and had fast labours.  My mom hemorraged with her 4th child due to retained placenta on a fibroid (but that wasn't the case with me last time).

Milomama - I too wonder about traction on the cord pulling things away before being completely ready to go..although I remember the doc looking "up there" with his headlamp on, looking for retained placenta and being unable to find any.  I would think that it would be hard to see microtrauma with all the blood anyway so who knows?  I also recall them saying that my uterus was contracting also.  So basically, I'm still not sure about the traction on cord/pitocen shot though.  Despite the evidence supporting it, I still wonder why it's a good thing when women have been giving birth to their placentas for centuries without tugging them out and giving themselves a shot? 

Could this evidence supporting active management of 3rd stage of labour be skewed by the fact that so many of the research subjects had interventions to begin with  that would impact the ability of their uterus to do what nature intended it to do?  I'll have to look into that.

I also wonder if having so much pitocen in me already desensitized my uterus to both the artificial and natural oxytocins?

Trinity - thanks for sharing the reassuring info that an IV can always get in somewhere :).  I'm leaning towards declining the IV if my blood pressure is normal and I go into labour naturally, as routine IV's do still can carry a small risk of nicked nerve/damaged vessels and I'd like to save my vessels for a time when I might really need it (like if I start hemorrhaging I guess....). But there's also a good chance I won't need an IV too I hope.   I guess I'll just take the risk of it needing to be done after the fact.  I can handle the poking fine.  I work on a general surgical ward in a smaller hospital and hear of patients all the time (much older than me) who've lost a lot of blood and who have been dehydrated and have very low hemoglobins requiring transusions...and all have had IV's put in successfully.  My midwife was saying that if someone is dehydrated or enough blood lost, that it can be really hard to get a line in....yet I haven't ever heard of it being so bad that no port could be found.  But maybe I'm wrong?

Thanks again ladies :)

[Smokering]

Could this evidence supporting active management of 3rd stage of labour be skewed by the fact that so many of the research subjects had interventions to begin with  that would impact the ability of their uterus to do what nature intended it to do?  I'll have to look into that.

Possibly. I had two separate midwives tell me when making my birth plan that they were fine with me choosing physiological third stage, but if I were induced they'd prefer to give me the oxytocin shot. They didn't explain why precisely, but made general statements along the lines of "Once you've started messing around with the natural hormones, sometimes you have to keep messing around". I agreed to it, but luckily I wasn't induced and the shot wasn't necessary. I might have bled less if I'd had it, but it was nothing too dire...

[kathrineg]

Well, women have been giving birth to their placentas without intervention for a long time, but unfortunately, post-partum 

hemorrhage has been around for just as long. PPH is not solely caused by intervention and is still a risk even in an intervention-free birth.

(I don't know why it's making that one word bold, sorry!)

[Lisa1970]

For me, IVs literally take an hour or more to start. So, I would probably do a capped IV if I were worried. I don't know if you have good veins where they can get the IV in with ease or not.

[Dov'sMom]

I would do the capped IV; the risks of an IV are incredibly small, especially if they have plenty of time and ideal circumstances to get it in. If they're scrambling to put a line in deflated veins when you're already hemorrhaging, the chances of damage are much higher and you're going to lose a lot more blood than if it was in originally.

Then again, I let them put in a capped IV and I haven't had a PPH, so my risk tolerances may be different than yours.

I'd also agree to the pitocin drip after birth because again, the risks are really quite minimal. The cord traction would give me much more hesitation, as the jury is out on whether it helps or hurts. I guess I'd play it by ear, see how long it took to come out before I agreed to traction.

[Dov'sMom]

But also remember that a capped IV isn't just a needle; there's heparin going in too.

A couple of years ago, many people died from heparin, including in IV lines, because the heparin was deliberately contaminated by unscrupulous Chinese suppliers. So there is a risk. There's always a risk.

[tessie]

Originally Posted by Dov'sMom 

But also remember that a capped IV isn't just a needle; there's heparin going in too.

A couple of years ago, many people died from heparin, including in IV lines, because the heparin was deliberately contaminated by unscrupulous Chinese suppliers. So there is a risk. There's always a risk.

I think they use saline these days.
 

[Dov'sMom]

Originally Posted by tessie 

I think they use saline these days.
 

I didn't know that! Do they still call it a "hep-lock" if it's really a saline cap? Does it depend on the hospital?

[kathrineg]

Either they always do saline or it depends on the hospital, the hospital where I'm going to deliver uses saline. 

[Dov'sMom]

I'll have to ask my midwife how it works in my hospital. I know they definitely told me they were putting in a heplock last time, but if saline is an option, I'd rather that.

[tessie]

Originally Posted by Dov'sMom 

I'll have to ask my midwife how it works in my hospital. I know they definitely told me they were putting in a heplock last time, but if saline is an option, I'd rather that.

I have a feeling it's still generally called a heplock, even when it's saline.

[by-the-lake]

Don't worry ladies. No heparin for pregnant ladies! Hep-lock is just an old term. Its all saline now. The devices on the ports cause negative pressure when flushed with saline, and that keeps the line 'open', so there is no need for heparin these days!