previous post partum hemorrhage - will it happen again?

[mercii]

I am currently expecting my 3rd, due the beginning of December. Both of my previous births went fast (5 or 6 hours start to finish) and were natural, in a birth center. First birth was pretty normal (though scary mentally) and the 2nd birth went well mentally (I was more prepared for what to expect), but I had a severe hemorrhage very soon after delivery. My midwife gave me every drug she had to stop the bleeding, and she estimates I lost around 1500 ml of blood or more.

I have researched heavily online about pph and cannot find any studies that show that there is an increased risk of pph if you have had a previous hemorrhage. Yes, pregnancy websites often list it as a risk factor, but it isn't mentioned in any studies I have found. I have zero risk factors as far as I can tell (though I am a redhead... is that a risk factor right there? )

I'm starting to take red raspberry leaf, chlorophyll, and nettle to help with uterine health and strength and increase my vit K for clotting and hemoglobin. I'm 18 weeks along currently, and have been getting prenatal care from my midwife, but I really have to make a decision soon as far as where to deliver. My husband was pretty alarmed about all the blood and wants to go the hospital route this time. I love my midwife, however, and she has a lot of experience, and I feel we can be better prepared this time. She is willing to deliver again.

I'm just wondering if there are any other people out there who have had severe pph, and then went on to have a normal delivery later. Should I be afraid to deliver in a birth center? Am I being irresponsible to do this? I would love to hear accounts from other ladies who have dealt with this before.

[Mamabeakley]

Have you discussed with your midwife WHY you may have had such a severe hemorrhage?

I had one PPH, after a 22 hour labor and with retained membranes.  I was also anemic at the start of labor.  So I'm pretty sure that was due to exhaustion and there being something in the uterus preventing it from clamping down (the anemia isn't a contributing factor to having a PPH afaik but it makes the recovery harder).  I have since had 2 normal labors and births, much shorter, no retained membranes, no PPH.

My SIL has had 2 or 3 PPH, for 2 or 3 different reasons (I can't remember how many or why atm.)

Some reasons might be more likely to recur than others.  If you can figure out why yours happened or make an educated guess, that might tell you more about your risks.

Having had one, even though I think it is unlikely to recur, prevents me from really ever wanting to have a UC, or a midwife who doesn't have access to pitocin and methergyn.  Herbs and homeopathics are good and I'd like to use them first if possible but if I'm bleeding out, give me the drugs!

Also, although there is the availability of a blood transfusion in the hospital, or a hysterectomy I guess, the medications they would have available to give you to stabilize you short of that point are the same as what it sounds like your midwife has available in the birth center.  Many hospitals give 'just-in-case' pitocin to every mother immediately pp to prevent hemorrhage.  You could probably choose to have your mw do the same, whether you have signs of PPH at the moment or not.  And, assuming that there is a good transfer arrangement, you might could get the care you needed from the hospital (if you did need it) nearly as quickly as if you gave birth there.

Things to think about/discuss with your midwife and spouse, anyway.

[mercii]

There was no retained membranes or placenta, and she speculates that it may have simply been clotted blood preventing the uterus from contracting. However, I wonder myself if it maybe have had to do with an extremely fast last stage of labor -- I honestly feel like I skipped the transition stage. My contractions were quite manageable while I was lying in the tub, then I stood up to get out of the tub, and BAM. I was pushing, and she was out in 2 contractions. I barely even realized what was happening before her head was out. I had no unbearable moments or feelings of "I can't do this" -- I seemed to skip all the worst parts of labor. If she "fell" out of me, maybe my uterus didn't have chance to contract enough behind the baby's exit, and was left "wide open"? (I haven't discussed this theory with my midwife, though I intend to on my next appt.) I did have low iron levels too, although not low enough to be considered anemic.

My midwife does have everything on hand that a hospital would use. The only thing lacking was blood (Since I stabilized I opted not to get a transfusion, and chose to be very weak for the next couple weeks!) The hospital is just 5 minutes away, so transferring isn't a big risk either.

My husband really likes my midwife and would like to avoid a hospital as well. The only thing holding him back is the fear that if something went wrong, he could never forgive himself. I understand his concerns, of course (bleeding to death is a scary thought to me, too!), but I don't feel that we're being irresponsible if we use the birth center again.

[holly6737]

History of PPH makes it more likely that you will have another PPH. It doesn't mean you definitely WILL have another PPH, but you are at greater risk, especially if it was due to something other than retained membranes or laceration. I have to disagree that your midwife has everything the hospital has at it's disposal. I'm not trying to talk you out of homebirthing, because I think homebirth can be a safe option for low risk women when attended by educated providers, but I do think you should acknowledge the reality of what your midwife can offer you at home. She can't offer you blood (which you mentioned), she can't offer you a D&C to clear out any retained membranes, she can't offer you repairs of certain lacerations (cervical lacerations come to mind, as they bleed particularly heavy) and she can't offer you an OR in case you need compression sutures, uterine artery embolization or even emergency hysterectomy. It's up to you whatever you would like to do, but yes, you are at an increased risk for PPH having had one PPH already in the past.

[mercii]

Thanks for your reply, Holly. I do realize that of course she can't offer more invasive operations that may be necessary, but correct me if I'm wrong -- these would only be done in a hospital if the drugs weren't working. My midwife is fully prepared to transport quickly. This is something I would like to be more knowledgeable about if possible. I'm not sure just how much time there is in a hemorrhage, and I guess that is the risk involved. (BTW, she did mention that she could manually check the uterus for remains of anything. As far as I can tell, only a few midwives do this, and it sounds terrible. I would hope I could avoid that at all costs...)

You say that a PPH does increase my risk for another one. Do you know why this is? Is my uterus just more lazy than some women's? Or am I lacking a nutrient, possibly?  Or do I possibly have a defect or something on my uterus that prevents it from performing correctly? I really wish I had answers for WHY this happened, and all my research on "atonic uterus" hasn't helped me much. :(  Also, I've been trying to find studies that back this claim up. I've been trying to present all the facts to my husband (and myself) and have only found anecdotal evidence for this.

[holly6737]

Yes, you would only have those invasive procedures if the drugs didn't work first. It is imperative if you have a PPH that your midwife transports very quickly. A lot of blood can be lost in a little amount of time, but if you have a PPH at home and your midwife transfers expediently, then you can still have a very good outcome. IMO, if you get to the point where she's having to give you methergine and/or other uterotonics, then it's time to call an ambulance. So far as checking the uterus manually (uterine exploration), this is going to be a very uncomfortable procedure without anesthesia. But, sometimes it's necessary in a PPH as the clots in your uterus can prevent the uterus from clamping down effectively. (Also, if she has to do that, be on the lookout in the next days-week for uterine infection.) I'm glad she's able to do that, but again if she's having to clean your uterus out manually, it's probably time to transport.

The reasons why women hemorrhage are the 4 T's: Tone (most likely cause), Trauma, Tissue, Thrombin (least likely cause). So, tone, uterine atony. You already know about this. There are things that can increase your likelihood of having a tired uterus. Those are polyhydramnios, macrosomia, and a long labor- among others. Trauma- any lacerations. That includes perineal and cervical lacerations. Your midwife needs to know what to do if there is a cervical laceration (gauze with ring forceps to clamp the laceration, then transfer). You can lose a lot of blood with a cervical lac, especially if it goes undetected. It doesn't sound like this was the problem with your last PPH.  Tissue- retained membranes. Partially detached placenta, etc. Again, doesn't sound like this was the problem. Thrombin- Any clotting disorders. Factor V Leiden, etc. These are rare (1% of PPHs) but do happen.

I would imagine that trauma and tissue would be less likely to repeat themselves. Thrombin will repeat itself, because you're always going to have that clotting disorder. Would tone repeat itself? It could. Maybe you just have a uterus that isn't as effective at clamping down. Or, maybe it was a one time thing because your midwife didn't do enough fundal massage after delivery of the placenta, which allowed the placenta to get boggy, which allowed clots to be retained in your uterus instead of expelled with fundal massage, which made your uterus even more ineffective in clamping down, which made you bleed. (This is why I think fundal massage is so important after delivery of placenta, and then frequent fundal checks thereafter.) It's hard to know exactly what happened. If you are going to go forward with a homebirth, I would make sure you have a midwife who really knows how to manage PPH, who carries uterotonics and who isn't afraid to transfer ASAP when a PPH happens. Be on the lookout for any symptoms of PPH and be aggressive in managing it. It doesn't mean you WILL have a PPH again, but, you know, I'd definitely be on my toes. I hope you have a wonderful delivery. :)

[mercii]

Thanks so much for your help! I really appreciate it.

I am due for another prenatal checkup within a week or so, and I hope to discuss this with her further. My memory of the post partum care last time is rather hazy, but it did seem there was some delay in delivering the placenta. (I have this vague recollection me saying that I couldn't and she demanded that I had to. If I'm remembering correctly, this would have been nearly an hour after delivery, and the same time we realized I was bleeding badly. However, I'm definitely not positive this is the case and will have to clarify it with her.) I have read a bit about placenta delivery but have read two totally opposite sides -- doctors appear to prefer helping the placenta out asap to prevent a hemorrhage, while the other side seem to commonly prefer letting it come purely on its own.