Valerie Gommon Midwife’s Blog

Homebirth and postpartum haemorrhage

Posted on: January 2, 2012

This is a guest blog written by Sarah Ward.

 Homebirth & PPH

Women often worry about what would happen if a woman bled heavily after a home birth. Throughout history, severe blood loss has been one of the main causes of women dying in childbirth, and it remains the most common cause of maternal death in the world [WHO, 1994].

Efficient management of postpartum haemorrhage is one of the wonders of modern obstetrics. The key is the availability of oxytocic drugs, which make the uterus contract down and normally stop bleeding.

You can choose to have either a ‘managed’ or a ‘physiological’ third stage, at home or in hospital. A ‘managed’ third stage means you have an injection of syntometrine as a precautionary measure. A ‘physiological’ third stage means you take a ‘wait and see’ approach to the delivery of the placenta, and only have drugs if you are worried about bleeding or if the placenta is taking longer than you want to wait for it to turn up

Sometimes one hears of doctors trying to dissuade women from home birth because of the risk of postpartum haemorrhage yet in fact severe bleeding after a home birth in the UK is rare, and postpartum haemorrhage is usually managed at home or by transfer to hospital. Despite the fears of some doctors, you would be very unlikely to bleed to death after a planned home birth in a developed country.

A famous review of quality studies of home birth (Olsen, 1997) looked at outcomes for over 24,000 women and found no maternal deaths. The National Birthday Trust Fund study looked at around 6,000 planned home births in the UK, and found no maternal deaths.

Where treatment for postpartum haemorrhage is needed, there are two elements. Emergency treatment focuses on stopping the bleeding, and in severe cases, keeping blood volume up while the bleeding is stopped. The other element of treatment is helping you to recover from blood loss, by administering a blood transfusion or iron supplements, this usually occurs several days after the bleed after blood tests have been performed.

What can a midwife do about heavy bleeding at a home birth?

Your midwife would follow exactly the same steps that she would take in hospital. Oxytocic drugs to manage blood loss are part of the basic kit that midwives take to every home birth.

If these did not bring the situation under control quickly then an ambulance would be called, and the midwife would take other steps if necessary, such as manually compressing your womb to stop bleeding.

In the UK most midwives can put an intravenous drip in at home while they are waiting for an ambulance to arrive.

What if the midwife isn’t there?

In the rare circumstances that a baby is born so quickly the midwife has not arrived yet, or the bleed has occurred after the midwife has left (also extremely rare), then you can do the following:-

  • ·       Call 999 if you can’t get hold of your midwife immediately
  • ·       Massage the uterus firmly – this often stops the bleeding immediately
  • ·       Pass urine
  • ·       Bi-manual compression – only if bleeding is extreme – involves someone continually massaging uterus externally and internally until help arrives

When the midwife arrives…

  • ·       She considers what we call the 4 T’s: Tone, Trauma, Tissue and Thrombin (clotting) factors.
  • ·       She can make sure the woman has passed urine and does not have a full bladder.
  • ·       She can use massage of the uterus, syntometrine or ergometrine medication to try stem bleeding. These medications induce a sustained uterine contraction. The massage of the uterus will sometimes expel any tissue obstructing good uterine clamp-down.
  • ·       The midwife can check for a tear, sometimes we can tear internally and it be less obvious
  • ·       Bi-manual compression will be used and transfer to hospital will happen as soon as an ambulance arrives if bleeding is not slowing.
  • ·       If bleeding has been easily stopped and woman feels fine then she may end up declining transfer to hospital. However in hospital they can offer a number of extra helpful interventions for anyone who has experienced or is experiencing a life-threatening PPH.

Placental Problems

  • ·       Occasionally the placenta doesn’t separate properly and obstructs, the midwife can manually remove it allowing the uterus to contract down and stem the bleeding

Can more be done in hospital than at home?

  • ·       The answer is yes, but only because there are more staff on hand, however the chances of having a life threatening PPH are far far greater in a hospital than at home in the first place.
  • ·       The most common reason for PPH is to do with atonic uterus, where the womb fails to contract down properly. At home, this is dealt with in the same way and with mostly the same drugs that would be used in hospital.
  • ·       It’s important to mention that PPH at home is reasonably rare, by the very nature of the fact that the major risk factors for PPH are things which only happen in hospital (instrumental deliveries, long hours on syntocinon drips, caesarean section etc).
  • ·       The last confidential enquiry into maternal deaths listed approx 5 deaths from PPH, all of which were in hospital, four of them were following instrumental deliveries and one following caesarean.

 How likely is post-partum haemorrhage after a home birth?

  • ·       PPH is significantly less likely to happen after a home birth than after a hospital birth.. This is probably because home birth reduces the risk of interventions which can contribute to PPH
  • ·       For more info, see the National Birthday Trust Fund study in the first instance, but numerous other studies have also found a reduced PPH rate in planned home births.
  • ·       Part of the reason for higher rates of blood loss after hospital birth is that PPH is statistically more likely to occur after intervention such as caesarean section, assisted delivery (forceps or ventouse), or medical induction or augmentation of labour (having a drip to speed labour up). None of these things will be happening at home. If you were to have any of these interventions, you would already be in hospital.
  • ·       There are some ways in which planning a home birth actually reduces your chances of having a PPH. Simply planning a home birth significantly reduces your chances of ending up with a caesarean or an assisted delivery – labour just seems to progress more smoothly at home, leading to less call for intervention. As these interventions increase the risk of PPH, by reducing the risk of the intervention, you are reducing the risk of PPH.

Can you have a home birth after having had a PPH with a previous baby?

  • ·       To try to work out the chances of a PPH recurring, and whether this is ‘safe’ for a home birth, you’d need to know why the PPH occurred, and if the same circumstances were likely to recur.
  • ·       Much depends on how you felt after the PPH.  Some women feel great even after losing a considerable amount of blood whereas others may feel terrible only losing 300ml.
  • ·       Its often hard to accurately measure the amount of blood loss. In the UK we call a loss of 500ml a PPH, but Europe don’t record a PPH unless over 1000ml.
  • ·       What were the circumstances the PPH occurred in? Were there known risk factors for PPH which would not apply this time? For instance, PPH is more common after assisted deliveries, first babies, large babies, induction or augmentation of labour.

o      If she needed an assisted delivery this time she would transfer to hospital, so that shouldn’t affect her status as regards home birth.

o      Likewise, her labour is not going to be induced with prostaglandins or augmented with syntocinon.

  • ·       Was the PPH a ‘true’ PPH in terms of being blood loss from her uterus, or was it associated with perineal tearing or episiotomy? Blood from both sources ends up in the same measuring jug, but the difference is significant.
  • ·       Did she have a retained placenta, or did the bleeding occur after the placenta was delivered – some ‘uterine atony’ involved?

Conclusion

All in all the risks of a PPH are lower in a planned homebirth than in a planned hospital birth.

However if one should occur, there are many ways it can be treated successfully at home, or by transfer to hospital.

It’s also important to realise that a negative outcome from a PPH can also occur in a hospital situation as well as at home.

Having experienced a PPH following a birth is not an automatic barrier to home birth in the future, it would depend on the reasons why it occurred. In fact planning a home birth may significantly reduce the chances of having a PPH in the future.

 

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2 Responses to "Homebirth and postpartum haemorrhage"

What a very useful blog post. may I adapt it to use with my clients when discussing this issue? Love Liz x

I’m sure Sarah would be delighted! x

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