Originally Posted by flapjack
Can I ask, Kavita, how do you define a PPH?? Do you use an estimated blood volume lost, or do you go more off how the mother is, and if she's showing any signs of shock etc?
Spughy- if I understand correctly, one of the reasons that our blood volume increases in pregnancy is because we're going to lose a fair amount of it when the placenta comes away at the end of it: the body already has a management strategy in place, if that makes any sense?
I will quote here from my well-worn (both frequently read, and partly chewed by my dog when she was a puppy!) copy of Varney's "Nurse-Midwifery, second edition" textbook:
"Hemorrhage, by definition, is an abnormal loss of blood. In obstetrics this is considered to be a loss of 500 milliliters or more." (Note from me: 500 ml. is 2 cups. This is quite a bit of blood, and I rarely have seen people lose more than about 100-250 ml., about half a cup to a cup, throughout the entire third stage process. But I digress!) "One does not, however, wait until there has been a loss of 500 milliliters of blood before deciding that the woman may be hemorrhaging and taking action. In fact early action in the presence of excessive bleeding may prevent actual hemorrhage and certainly the life-threatening sequelae of hemorrhage that are first manifested by the signs and symptoms of shock."
The point here is that there is a pretty big place in between NORMAL postpartum bleeding and postpartum hemorrhage, called, "Hmm, she is bleeding a bit more than I'd like, and I need to take some action and get her uterus contracted now to prevent a hemorrhage from occurring." The first step of this if the bleeding is not too severe/fast would be to try nursing, or nipple stimulation, or uterine massage to contract the uterus, and the next step is to adminster pitocin through intramuscular injection. In my experience, it is not very common that this situation actually develops into an actual hemorrhage when managed correctly. You can also identify certain factors which put a woman at risk for hemorrhage, and be more alert to the possibility and act earlier in those cases. There's some consideration of the woman's condition that I put into the decision (for example, what her overall condition is before she started bleeding a bit too much) but mostly it's just evaluating what is going on in terms of the rate/type of bleeding (trickle? gush? steady stream? getting faster or slowing down?) combined with the total amount of blood being lost.
Of course, the book also notes that we can in fact identify in labor women who are more at risk of/predisposed to the possibility of postpartum hemorrhage. Some of these risk factors are just natural, like uterine overdistention due to a really big baby or multiple gestations, or grand multiparity. However, one OTHER major factor is that the use of oxytocin induction or augmentation of labor predisposes a woman to immediate postpartum hemorrhage due to uterine atony! In most hospital settings it is not at all uncommon that women are given pitocin to start labor or speed it up. In fact, this is a cornerstone of the philosophy they call "active management" which basically stresses that labor should be over and done with within certain specified time frames and pit should be used to speed things up if the body is not conforming to this pattern--which is especially the case even among hospital midwives in places like Ireland and Australia and I believe parts of Europe. It makes sense that there would be a higher rate of postpartum hemorrhage amongst these women, and that studies done on this population with a large percentage of at-risk people would indicate that use of pitocin after birth does in fact lower rates of postpartum hemorrhage. Never mind that it is the management of birth in the first place that is CAUSING at least some increase in the rate of postpartum hemorrhages, that they are then trying to prevent by giving pitocin postpartum to everybody! It's like by giving someone pitocin in labor, you sort of cause the uterus to kind of get confused and stop listening to the body's own hormonal signals, and it just poops out after the birth and stops contracting, and therefore bleeds more. Also, any uterine massage or pulling on the cord during the first part of third stage tends to cause more bleeding. Since I never give pitocin to induce or augment labor and don't cut the cord or massage the uterus before the placenta is out, I just don't see this problem very often in homebirth.