Hemabate: Needed? Doseage Correct?

[Novella]

I'm interested in having birth professionals weigh-in on the amount of Hemabate I was given for post-partum bleeding after my twin delivery 8 months ago.

I had a very easy vaginal birth of both babes. I refused the standard injection of syntocinon that is usually given immediately as part of active management of the third stage.

I had continued bleeding that the doctor described as a small, but persistent area in the back of the uterus that would not firm up. Attempting to nurse babes did not seem to abate it much. She instructed my support person to administer uterine massage. We tried this for 45 minutes. Bleeding always slowed during massage, but if massage stopped for even several seconds, the bleeding renewed. Doctor removed many soupy, stringy clots from inside the uterus several times throughout the 45 minutes. At that point, she fairly insisted on pharmaceutical assistance. I felt fine. But doc felt that the situation was not improving and estimated I had lost 800ml blood. She also mentioned something about wanting to go home. . . :

I was intent on the minimum required, but unfortunately was relying on her for this information. Doctor explained that 5 units of Hemabate would be the lowest doseage in practical use. She recommended 10 units in my case, which I consented to. When I examined my medical records a few months later, I discovered that I had been given 20 units of the drug (4 times what she described as the minimum dose!) I also received Syntocinon while they were preparing the Hemabate.

The bleeding stopped quickly. The associated horrid diarrhea quickly followed.

The situation continues to bother me. I can't help but wonder if using Hemabate in this scenario was akin to killing a mosquitoe with a sledgehammer. Was it really time for Hemabate at that point? Or was my doctor just cheezed that I refused the Syntocinon prior to delivery of the placenta? Would you have thought it appropriate to use Hemabate?

I am also interested to hear any thoughts about the doseage, particularly since it was double what the doctor had told me she would administer. The nagging concern I haven't been able to put to rest is that she purposely gave me more than necessary in a vindictive move (re: the "pleasant" side effects) because we had very clearly bruised her ego in refusing many of the standards of care she demanded for the delivery.

Please don't sugar-coat. . . if I got a "good nasty" that I needed at the time, just say so. But if my paranoia bears out, please tell me. Either way, it will help me put the matter into perspective and stop wrestling with it!

[mwherbs]

I don't like repeated massage of the uterus- a light touch a uterus will usually respond if it doesn't then a firm grasp and hold- if that doesn't work then it is time for something else- since you were in a medical setting then herbs are really not on the menu-- I would give 1-2 shots of pit or some pit with methergin(which is what I think syntocin is)-- and I tell you they used a great deal of reserve because 500 ml is a hemorrhage and if I have seen anything is usually a underestimation of blood loss in the hospital-so waiting till they figured you had lost 800ml is a long wait
I cannot tell you anything about hemabate though-- just that it seems that they did take your concerns and wishes seriously---

[berrymama]

This probably does not answer your question, but here is some info:

Hemabate is not a Unit dosage - it is measured in micrograms (mcg). A standard dose is 250 mcg in a 1 ml muscular injection. This may be repeated if needed.

Pitocin is measured in units and is given as a 10 unit IM injection, or 20 units diluted in an IV of 1000ml of Lacated Ringers.

[DoomaYula]

Well it does sound like they waited a while -- when I've seen hemabate given, it was within about 10 min of birth -- and 800ml is considered a hemorrhage, so in my non-professional opinion I think they were okay. Given the diahrrea associated with hemabate, pitocin seems like a better option for a first response.

[Novella]

Thank you for your responses. It appears I have something mixed up in my memory:

Originally Posted by berrymama

Hemabate is not a Unit dosage - it is measured in micrograms (mcg). A standard dose is 250 mcg in a 1 ml muscular injection. This may be repeated if needed.

I have it written down, so will have to look up my note again. . . maybe the 20units was the Syntocinon (Pitocin) that they gave me. Now that you mention it, the 250 mcg rings a bell. (Sorry for the confusion!)

I realize that estimated loss of 800ml is technically classified as a hemmorhage. Based on our research for the birth, my husband and I had set 1000ml blood loss as our threshold for considering pharmaceutical use. We expected higher blood loss since it was a twin delivery.

Just to clarify: The hospital didn't use any "reserve" about administering the drugs. Throughout the delivery of the placenta and subsequent 45 minutes of uterine massage, I repeatedly declined the doctor's suggestions that we should use drugs to speed up the whole process.

That is part of what makes me wonder if she gave me more than agreed to (more than necessary?) because she was angry that we wouldn't agree to her plans for the delivery. It seemed that by the time the babies were out, she had simply labelled me as a stubborn, ridiculous woman who was unnecessarily keeping a poor pregnant doctor away from her bed at home at 5:00am.

[Jane]

You know, I know a lot about hemhorhage and pp uteruses for singletons, but I don't know a lot about twins, post-partum. To me, a uterus that won't firm up nicely, especially with trickle bleeding, requires treatment and pretty continuous monitoring to make sure things are not getting worse.
Treatment could be lots of things, incl. pharmecueticals. Not being there, seeing the clots, feeling the uterus...still seems like a reasonable plan. Once the uterus firms up, it usually stays that way. Perhaps pitocin might have sufficed alone, but it's seems not, since you got that first.
I sort-of understand the doctor, thinking that you ended up with medication anyway, and if you'd had it earlier, you'd have not had so much blood loss. They don't put a lot of value on the physiological process, or the effects of disrupting that, and the psycological impact on the mother.

Don't discount that the charting nurse wrote things down wrong. sometimes the doc will say "I'm giving pit" and the nurse writes down the standard amount used b/c the doc didn't specify aloud.

[Novella]

Originally Posted by Apricot

Perhaps pitocin might have sufficed alone, but it's seems not, since you got that first.

Actually, the pitocin (Syntocinon) and Hemabate were given moments apart. I did not have the Syntocinon first as it's usually given here (ie. immediately after the baby is out, to facilitate delivery of the placenta). There wouldn't have been enough time for them to see whether the Syntocinon was doing anything and they did nothing to evaluate my bleeding, uterine tone, etc between giving the two drugs. By the time I agreed to take the drugs, it was presented as "we should do both" and both were given at virtually the same time.

Originally Posted by Apricot

Don't discount that the charting nurse wrote things down wrong. sometimes the doc will say "I'm giving pit" and the nurse writes down the standard amount used b/c the doc didn't specify aloud.

Thank you for raising that point as a possibility. I hadn't considered it, but I can certainly see that it would happen frequently and easily. I don't think it applies in my case, though. There was several minutes discussion at the time when I finally agreed pharmaceuticals might be appropriate. It was certainly a more drawn-out conversation than normal about what was the minimum doseage, what the doc felt I needed, what I should expect if I agreed, etc. Both attending nurses were present while this was being discussed.

Thank you for the continued responses. I do appreciate it.

Since in my original post I had the doseages mixed up for Syntocinon and Hemabate, can anyone comment on the units of Syntocinon I received? (As a refresher: Doc said 5 units the regular minimum dose but that she thought I should be given 10 units. Medical records say that 20 units were administered). Would 20 units have been something one could consider a strong, yet appropriate response for persistent bleeding? Or would it have been an unusually high dose? I'm still a little confused also about why both Syntocinon and Hemabate would have been administered together. Since reading more about Hemabate post-partum, it seems like such a powerful drug that I can't help but wonder if it wouldn't just completely overpower any effects of Syntocinon. Any thoughts using them as a combo like that?

[mwherbs]

"Doc said 5 units the regular minimum dose but that she thought I should be given 10 units. Medical records say that 20 units were administered). Would 20 units have been something one could consider a strong, yet appropriate response for persistent bleeding?"

so the doc mis-stated the minimum dose of syntocin it is 10 and 2 doses would be 20 and makes sense to me- once you have bleed that much--
I am wondering how you came up with the 1000ml blood loss as reasonable? just because there are 2 babies and a degree of increased blood volume to match- there are not 2 mom's - so double the blood loss doesn't sound that good to me-- women can appear fine after a blood loss/hemorrhage for a while because they compensate the pulse increases and the circulation changes- but there is a limit and it doesn't sound like you were near it but some women may have been- and lets say that the shots they gave you did not work- then what? there is no time or blood volume to play with to keep working-- so although I don't agree with the pace of an immideate shot in every case- if babies are latched and attached and the bleeding is still excessive-- preserving the mother's blood volume is a priority - doing something manually or giving shots would be something to do sooner rather than later- also and IV sounds like a decent idea as well--
------ now I have seen several severe hemorrhages some women pass out some seem almost fine I think that it is hard to tell when too much is too much sometimes until it is too late-- were you anemic? in the early days postpartum were you able to function well? did you stay well, get any infections or ....? if you were fine then you did what worked for you --- but frankly reading your story causes me a bit of concern-- and to say it again I don't use pit often--but if I could avoid having a woman loose 800 ml I would, I think given that I practice in homes and not a hospitial I really could not afford to - ignore bleeding until it was 1000ml before I did anything to treat it .

[Jane]

20 units of pitocin is a loading dose into an IV bag - to drip in over 20-60 minutes. 10 units is usually given intramuscularly, sometimes followed by more doses.

[Novella]

Originally Posted by mwherbs

I am wondering how you came up with the 1000ml blood loss as reasonable? just because there are 2 babies and a degree of increased blood volume to match- there are not 2 mom's - so double the blood loss doesn't sound that good to me

Yes, I certainly understand your point that in spite of up to 500ml being considered normal blood loss for a singleton delivery, there's still only one mother, in spite of there being two babies. We didn't just multiply singleton blood loss by two.

These are some of the reasons we chose 1000ml of estimated blood loss as the threshold where we would consider that pharmaceutical management might be appropriate:

• According to my research, blood loss of between 500ml and 1000ml is relatively common in a twin delivery.
• While the perinalogist we had planned to deliver with (but ultimately didn't get to) had preferred we agree to immediate third-stage pitocin, she agreed with us that pursuit of a drug-free experience was reasonable, because she felt that the variety of drugs available gave her many "tricks up her sleeve" and that the chance of a hemmorhage that didn't properly respond to the drugs was very small.
• The first time I ever donated blood, the machine didn't shut off properly and they collect quite a bit too much. There was a small panic and scurry about making sure I was feeling OK, etc etc. I had absolutely no ill-effects from that experience. I also reasoned that if a simple blood donation is a bit less than 500ml, this is based on quite a margin of safety.

Originally Posted by mwherbs

doing something manually or giving shots would be something to do sooner rather than later- also and IV sounds like a decent idea as well

Well, I guess if by "doing something manually" you include fundal massage, then that was happening within minutes after the second twin's birth, and went of for 45 minutes before we decided it just might not be successful enough. I wasn't bleeding a lot throughout. It was slow, but consistent. So it was the absence of improvement that my husband and I finally felt might warrant the use of drugs. Really, I wanted to put a piece of the placenta in my cheek. But I was too chicken to ask about that after I already knew they thought I was a horrible patient and obstinant weirdo. :

Originally Posted by mwherbs

were you anemic? in the early days postpartum were you able to function well? did you stay well, get any infections or ....?

I was slightly anemic early in the twin pregnancy, as I had been with my third child (the previous pregnancy). I am not normally anemic. In both of these pregnancies, iron supplements seemed to fix things up quite satisfactorily on the regular blood tests. I was not anemic at the time of delivery. Here I go demonstrating my ignorance again (I think this is related): My blood was tested about 5 hours post-partum. The nurse said the level (hematocrits maybe?) was 14.2 which she described as excellent, especially considering the blood loss. So she said I must have had plenty of iron in my system going into the delivery.

I felt fine. My blood pressure was checked frequently during the 45 minutes prior to accepting drugs. One or two readings were a very slightly low. But all perfect other than that. I walked around without any concerns when moving out of the delivery room about 90 minutes post-partum. I was ready to go home when the IV finally came out at 5 hours post-partum and I stayed well. No dizziness, infection, fatigue, etc that day nor in the days ahead.

Thank you, mwherbs, for your explanation about normal doses of Syntocinon.

[Novella]

Originally Posted by Apricot

20 units of pitocin is a loading dose into an IV bag - to drip in over 20-60 minutes. 10 units is usually given intramuscularly, sometimes followed by more doses.

Thank you, too, Apricot. You posted while I was creating my (as-usual) long-winded response to mwherbs!

[mwherbs]

sounds like everything was all well with you- and that was good, excellent actually.probably they were counting the clots in with the blood loss- because it is blood loss as well--
BP is one of the last things to change and I would not rely on it as an indicator of well being during or after a hemorrhage --
I wasn't thinking in terms of IV drugs but Apricot has it right-- I only use IM pit-- no IV pit--- although for a hemorrhage I would give IV fluids--
now the 1000 as a common blood loss for twin birth has to do with C-sections that is a common amount of blood loss for a c-section

[Novella]

Originally Posted by mwherbs

now the 1000 as a common blood loss for twin birth has to do with C-sections that is a common amount of blood loss for a c-section

Hmmm, this continues to be interesting. Thanks for your further input! Just to clarify: Do you mean that up to 1000ml blood loss is consider normal for twin deliveries only if they are c-sections? And that vaginal twin births would have a lower normal threshold?