Q: What steps do you take in your practice to avoid postpartum hemorrhage (PPH)?
Don't cause it! (hands off during third stage). Get baby to breast soon. Have mom push out the placenta, no pulling.
This may sound silly but I often "talk to" the placenta, thanking "Madame Placenta" for its wonderful function and now, would you please come out? I think this calms me down (if it's a long third stage) and it calms the family and adds a little humor to an otherwise tense situation.
If the woman has a history of PPH, I will often offer her shepherd's purse tincture prophylactically, two droppers full under the tongue after the placenta delivers. Have her hold it under the tongue as long as she can stand it, then follow with a little bit of water to drink.
Massage the uterus and be very aggressive if you have to. Having worked over ten years in a hospital practice prior to doing home/birth center births, I learned to be very aggressive in this. I just put it down as a life saving measure and don't sweat not being nice.
Be aggressive with Pitocin followed by Methergine if the above doesn't help. The above measures have really worked well for me, and I very very rarely have PPHs.
-Annette Manant, CNM harmonyu@telisphere.com
As long as there is no (or very slight) bleeding, I wait for signs of placental separation. Sometimes if I need to stitch I go ahead with this, or just sit and admire the baby When the placenta has separated, I put a hand on the fundus to clue the mother in to when she has a contraction, and get her to push the placenta out. I do not find the test of placental separation where you push up the uterus and see whether or not the cord pulls up to be accurate. What this tells you is whether or not the placenta is through the cervix. If the placenta is separated but not through the cervix, I may assist the mother's pushes with controlled cord traction in the curve of carus.
I am more active if there is a lot of bleeding. After the placenta is delivered I make sure there are no clots in the uterus, then try to promote quiet time with privacy for mother and baby to tune into each other and get the baby onto the breast. The human body has natural mechanisms to stop the normal bleeding which goes along with childbirth before it becomes a hemorrhage, and I try to work along with these natural systems. However, I don't hesitate to use other, more interventive techniques if hemorrhaging begins. Too much blood can be lost very quickly.
-Marion Toepke McLean, CNM
Reprinted from Midwifery Today E-News (Vol 1 Issue 35, Aug 27, 1999)
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