Low Iron & Active Management

[Brisen]

I had an appointment with my midwife yesterday, at just over 36 weeks. A month or more ago, my iron was checked and found to be at 100, which is the lowest you can have it and still homebirth here. I was very, very tired over the week or so leading up the the appointment when my blood was drawn, and I already knew at that point that iron was the likely culprit, so I took steps to get it back up. I'm feeling much better now but have decided not to retest, just in case my numbers are lower. I'm keeping my 100!

So we discussed what this meant. My midwife said that they would usually give an oxytocin shot to help the uterus clamp down, and make sure to get the placenta out right away, using cord traction if necessary. I don't have any history of excessive bleeding following birth. I did have the shot after my first was born (hospital birth), but with my second and third children, I had a pushing urge shortly after the baby was born and the placenta came out fine on its own (both of those kids nursed right away). I told her I would prefer not to do the shot and traction, but if there were signs that it was needed, then I was fine with it.

So all that to ask if anyone has any experience with this -- personally I was wary as soon as she mentioned traction, as I thought that was now thought to cause more problems than it solved, like leaving bits of the placenta behind, which is exactly what you don't want when any excessive bleeding would be made that much worse by having low iron? Are there any other steps that I can take to encourage my placenta to come out well and my uterus to clamp down well? I haven't been terribly consistent with my RRL tea, would that help?

[MsBlack]

I would have to see a count below 9 (which likely translates to 900 on the scale your mw is using...either that, or your count was '10.0', rather than 100).....I would have to see a count below 9 before I worried about homebirth, or any form of active management for placental delivery. I do not see that any harm could be done with 'expectant management': that is, waiting and watching to see IF any 'help' is NEEDED. IF baby at breast does not make you contract enough to naturally separate placenta from uterus; IF there is too much bleeding; IF things do not go right, THEN give shot of pitocin and MAYBE some cord traction once it is determined that placenta has separated.

By the way, baby does not have to be latched on, merely AT the breast/nuzzling to prompt contrax to separate placenta and firm up the fundus.

I only use cord traction after an hour or more has passed since delivery AND I'm sure that placenta has separated; and I only use a gentle/firm pressure as mom bears down (mom in upright position). Usually, this works within a few seconds to bring placenta out--and if it doesn't, I'll stop and wait some more (assuming fundus is firm and low, and mom is not bleeding much). I consider even this to be questionable--but sometimes, placenta has separated but it falls flat across cervix and does not descend enough to give mom the pushing urge--especially if cervix is starting to close down again (smaller hole for placenta to get through). I am not saying that cord traction is NEEDED in these cases, but there are moms who would just like to get up and shower, and be done with the birth by that time so as to lay down and fully relax with baby--so if carefully done it can be useful to some women. As you mentioned, usually after placenta separates, it falls partly through cervix and mom feels urge to bear down.

but using cord traction to help separate a placenta from uterine wall is NOT SAFE and very likely to cause more bleeding! Even if pitocin has been given. It can also lead to uterus prolapsing partly or even inverting entirely--it turns inside out and protrudes out of vagina, requiring MORE interventions to repair and risking MORE blood loss. I have recently heard 2 such stories from doulas who watched this very thing happen with an over managed 3rd stage: immediate pitocin and cord traction leading to full uterine prolapse/inversion. Surely, you will have a few minutes to wait and watch--at least a few minutes. And to wait and watch for a longer time, if all signs are normal.

I think this mw is jumping to conclusions and that her thoughts on this are not evidence based. Maybe you want to consider discussing this with her...maybe even looking for another mw who is more trusting of birth than she is of her tools and skills.

[pamamidwife]

Here is what I wrote on my blog about this, but seriously, I think this is a really normal value for the end of pregnancy. Blood volume expansion, right?

http://sagefemme.blogspot.com/2007/03/fe-struggles.html


And definitely, just like Ms Black said, you're likely to face PPH with active management.

There is an erroneous belief that being "anemic" (which I don't think you are) causes more PPH, which is maybe where she is coming from.

[Brisen]

Thanks for the input -- it basically confirmed my own feelings on the matter, which makes me fell much better.

Originally Posted by pamamidwife

There is an erroneous belief that being "anemic" (which I don't think you are) causes more PPH, which is maybe where she is coming from.

One thing she did say was that being anemic doesn't make me more likely to have pph, but that the blood loss is a bigger deal because it's lower in iron... but yes, the timing of my extreme fatigue lined up with the 3rd trimester blood expansion, and I'm feeling far better now, so I'm personally not worried about my iron levels.

MsBlack, it's good to know that nuzzling will help.

Originally Posted by MsBlack

I would have to see a count below 9 (which likely translates to 900 on the scale your mw is using...either that, or your count was '10.0', rather than 100).....I would have to see a count below 9 before I worried about homebirth, or any form of active management for placental delivery.

I don't know what scale they were using... I just know they said my iron was at 130 at my 8 week appointment, and then at 100. And the midwives here work under rules that govern when they can and can't homebirth... if iron is below 100, they can't attend the birth at home, even if they believe that my low iron was a normal dip. Sigh.

[onelilguysmommy]

theres 2 numbers. one is supposed to be at least 11. something and the other is the higher, most places, it has to be 30 or 32. wow, if mine had to be 100 id be majorly screwed. mine was critical at 5mo, i washospitalized, argueing that the low iron wasnt screwing with my judgement to not have a transfusion...ugh.


anyway yours sounds good ro me... maybe they did mean 10 and they add an extra zero for their scale?
waaay better than mine anyway and were great, so oi wish you luck and a safe happy birth!