Ornament

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Ornament

Third Stage / Placenta / Postpartum Hemorrhage

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New Model of Mechanisms of Placental Separation and Expulsion



I found some interesting studies that seem to shed some new light on 3rd stage physiology. I'll put full references below, but basically they are the results of 'continuous, dynamic, ultrasound imaging of the 3rd stage of labour'. (dreadfully intrusive for women of course at this time and would affect their position - no mention of ethical approval!)

25 'patients' with normal spontaneous 'deliveries' and five with prolonged 3rd stage were studied, no hx of CS or pathological 3rd stage. First scan assessed placental location: 10 were anterior, four fundal and four lateral (we all know placentas can implant anywhere - but the pictures of 3rd stage in MW textbooks always show mechanism of fundal separation - not so helpful). Syntometrine was given for 3rd stage immediately after birth.

Here's the main findings:

"Real-time ultrasonography of the 3rd stage in patients with normal deliveries showed that immediately after delivery the placenta-free wall became thick and the placenta-site wall remained thin. Thereafter the placenta-site wall thickened gradually from <1cm to >2cm. At this point the placenta was already separated and could be seen detached from the uterine wall as it began a sliding movement toward the cervix. No haematoma was observed between the placenta and its adjacent uterine wall. Once the placenta began its movement, the zone of separation remained unchanged and a small amount of blood collected in the uterine cavity, indicating that bleeding during placental separation is rather a consequence and not a cause. In six normal deliveries gentle traction of the cord was applied before contraction of the placenta-site wall occurred. This procedure had no effect until all areas of the uterine wall had thickened, indicating that contraction should occur before detachment ensues. On the basis of this sequence of events we propose to divide the 3rd stage of labour into 4 phases: latent phase, contraction phase, detachment phase and expulsion phase......On the basis of measurements of the various phases, it is apparent that the length of the 3rd stage is primarily determined by the latent phase (median 3mins). Once the ensuing contraction phase begins, the other 3 phases are shorter and with less variability"

They go on to say:

In five cases of prolonged 3rd stage: "In four cases after a prolonged latent phase of 50-120, the contraction phase ensued, ending with both thick uterine walls. Now, gentle traction of the cord was successful and normal placentas were delivered.....in the fifth case, however, the adjacent uterine wall remained thin and after 120 minutes and adherent placenta was lysed and removed manually under GA.....our policy is to avoid interventions in the first 2 hours so long as no bleeding occurs.

"After completion of the study we followed an additional 6 cases in which oxytocic drugs were withheld. Those cases exhibited the same ultrasonographic findings"

Same authors did further study of 101 women with normal deliveries with focus on the actual separation:

Results: "Separation in 97 cases was multiphasic. Monophasic separation in which all parts of the placenta appeared to separate simultaneously occurred in only two cases. Pathological prolongation of the 3rd stage precluded determination of separation in 2 cases. 92 cases had a uterine wall placenta (anterior or posterior); the separation commenced at one pole and progressed sequentially towards the opposite side in 89 of them. The process started at the lower pole (down-up separation) in 83/92 cases (90.2%) and began from the upper pole (Up-down separation) in only 6/92 cases (6.5%). Nine cases had a fundal placenta; of these the separation was also multiphasic but began sequentially from either the anterior or posterior pole, or simultaneously from both in 8 (88.9%) cases so that the fundal part was separated last (bipolar separation)"

Interesting aye - not a particularly large study I know, but shows that our classic textbook picture of fundal placenta separating from the middle first aided by the retroplacental clot may be a load of &*%$#

Wonder if this info will ever filter through into MW teaching and texts?

Down-up sequential separation of the placenta.
Herman A, Zimerman A, Arieli S, Tovbin Y, Bezer M, Bukovsky I, Panski M.
Ultrasound Obstet Gynecol. 2002 Mar;19(3):278-81.

CONCLUSIONS: Placental separation is usually an orderly multiphasic phenomenon that begins mostly from the lower pole of the placenta and propagates sequentially upwards. Fundal placentae, however, separate first at their poles with the fundal part being separated last. Recognition of the sequence of events and understanding of the mechanism of placental separation may aid in detecting cases prone to third-stage complications and in managing pathological ones.

Gray scale and color Doppler sonography in the third stage of labor for early detection of failed placental separation.
Krapp M, Baschat AA, Hankeln M, Gembruch U.
Ultrasound Obstet Gynecol. 2000 Feb;15(2):138-42.

CONCLUSION: Cessation of blood flow between the basal placenta and myometrium following delivery of the baby is the sonographic hallmark of normal placental separation. Persistent blood flow demonstrated by color Doppler sonography is suggestive of placenta accreta.

Dynamic ultrasonographic imaging of the third stage of labor: new perspectives into third-stage mechanisms.
Herman A, Weinraub Z, Bukovsky I, Arieli S, Zabow P, Caspi E, Ron-El R.
Am J Obstet Gynecol. 1993 May;168(5):1496-9.

CONCLUSION: Shearing forces seem to tear the decidual septae and thereby separate the placenta. This process is completed only when the placenta-site wall attains full thickness. In cases of prolonged third-stage labor, traction of the cord should be applied only when this phase is completed and the actual sliding movement of the placenta is observed.



Prevention of Postpartum Hemorrhage




See also: Physiological Management vs. Pitocin


Does Controlled Cord Traction Reduce Postpartum Blood Loss By Jamie Habib | May 10, 2013

Pertinent Point: - Controlled cord traction used in high-resource settings does not affect the risk of severe postpartum hemorrhage. [Ed: AND if you have a particular need to prevent hemorrhage, it still makes sense to me to get the placenta out as soon as it's separated so that you can assess bleeding and take appropriate measures.]


Midwife Judy Cohain is offering a protocol which she says guarantees to keep blood loss under 1000cc for a vaginal birth:

Judy's 3, 4, 5 Protocol

At birth, immediate continuous skin-to-skin contact with the baby is initiated for the first 3½ minutes postpartum. If the woman requests cord cutting, don't cut the cord before 3 minutes. The midwife keeps her hands off the fundus. At 4 minutes the midwife directs the mother into a good deep squat with her bottom almost touching the floor and her feet flat on the floor or the floor of an empty bathtub, over a low plastic bowl if midwife wishes to measure blood loss. If the mother requests for the cord to be cut, the mother hands the baby to someone. The midwife gives verbal encouragement to push. The woman will not feel a contraction – she pushes without feeling a contraction. If the placenta is not delivered by 5 minutes 0 seconds, the midwife helps the cord to come further out by gently pulling it down about 5-15 cm in length in order to reassure the mother and herself that the placenta is very low and all she has to do is push. The woman is in a low squat while she pushes out the placenta. The time of delivery is noted. Immediately after delivery of the placenta, the mother is helped to put on an absorbent pad and underwear(optional), helped into bed, and immediately given the baby. The uterus is then immediately massaged to check for clots. If blood completely fills the absorbent disposable pad during the next five minutes, a shot of either 10 IU Pitocin IM or 0.2 mg methergine IM (intramuscularly), or both is given at 10 minutes postpartum. Early suckling at the breast is initiated. If a woman has a history of PPH>1000 mL at a previous birth, or if she is had twins, prophylactic methergine 0.2 cc IM may be considered after the placenta is delivered.

Judy has put up a YouTube video of this protocol in action.



Managing History of Postpartum Hemorrhage



I think all midwives should carry Cytotec for emergency use in case of postpartum hemorrhage.  Certainly if a woman has a history of PPH, it would seem especially important to do so!


I deal with "normal" women birthing at home.  Their infants are birthed up onto the women's chests and never leave their mom's skin for any reason. Mother is given a postpartum tea mixture and told "This tea will help your placenta come out smoothly, all in one piece" (hypnotic induction).  She is watched for bleeding as unobtrusively as possible but no other mention is made of the placenta for at least 30 mins., timed by the clock.  At the end of exactly 30 mins., almost all the women say "I'm feeling some more cramps now", they are told  to push for their placenta and most are out in about 45 mins.  I attend about 40 births per year.  I have not seen a p.p.h. in about 8 years.  I buy a prescription of pit ampules each year and at the end of the year I throw the whole bunch into my teaching box because they've expired unused.



Blood sugar issues can make it harder for the uterus to contract effectively to control postpartum bleeding.  Even if you "pass" all the blood sugar testing, you might want to consider self-monitoring at home to see how your diet is affecting your blood sugars, especially late in pregnancy.

I have sometimes wondered whether the purported association between redheads and hemorrhages is really about redheads and blood sugar issues in pregnancy.

Polly-Jean Five-Week Antenatal Formula -
Other formulas on the market have helped many mothers, but over the years midwives have found that these formulas did not assist enough in preventing hemorrhage in women with borderline anemia, the Rh-negative factor, and other conditions. We found that when pennyroyal was included in the formula, bleeding continued to be heavier than it should be. We also found that black cohosh seemed to increase the normally stepped up production of estrogen, adding to the hemorrhage problem. We eliminated both these herbs when we developed our formula.

In response to the question, does hemorrhage repeat itself, statistically, I learned in Midwifery School that there is a 16% increased risk of hemorrhage (specifically, post partum hemorrhage) with subsequent pregnancies. I think this is an acceptable risk (some may not). More importantly, exploring WHY the woman may have hemorrhaged in an attempt to avoid repeat circumstances prenatally is useful. Doing those things preventatively with nutrition (the midwife's "specialty" :-)) and discussing management with the mom should the situation recur are some approaches I take with this history. I suggest alfalfa tablets in the last 6 weeks of pregnancy in hopes of building up the client's natural Vitamin K. Nutritionally, I try to make sure that she is not "anemic" using food sources for building iron, suggest lots of alfalfa sprouts, onions, and garlic for Vitamin K, and sometimes have them drink a tea of raspberry leaf/nettles/shepherd's purse the last several weeks.


My friend who does home births recommends Shepherd's Purse.  They encourage this for all their moms, not just those with hx of hemorrhage, but it would be especially important for them.  They have used this for about 10 years now and have found it very helpful.


Also try yellow dock tincture. 3 droppers 2 xa day. This will help all the iron be absorbed in her body. Also dandelion root tincture is high in iron...same dosage. These 2 together is an alternative to L. Chlorophyll or if she's real anemic try all of it:


Chinese Medicine for Third Stage



Timing of Placental Separation



Study of the third stage of labor by color Doppler sonography.
Krapp M, Katalinic A, Smrcek J, Geipel A, Berg C, Germer U, Gembruch U.
Arch Gynecol Obstet 2003 Feb;267(4):202-4



Physiological Management vs. Pitocin




Risk of Severe Postpartum Hemorrhage in Low-Risk Childbearing Women in New Zealand: Exploring the Effect of Place of Birth and Comparing Third Stage Management of Labor [full text]
Deborah Davis PhD1,*, Sally Baddock PhD2, et al.
BIRTH 39:2 June 2012
Article first published online: 17 MAY 2012

Conclusions: Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management.


Active versus expectant management for women in the third stage of labour from the Cochrane Collaboration

Notice that while there was a reduction in transfusion rates, there was also an increase in women returning to the hospital after discharge for treatment of abnormal bleeding and no difference in bleeding at levels severe enough to cause symptoms. Henci Goer wrote the chapter on third-stage management as co-author of her new book.  She writes, "The excess percentages were low and identical (1-2%), so essentially you are trading a small potential for solvable bleeding problems right after birth for the same potential later on. Furthermore, any reduction in immediate postpartum excessive bleeding does not take into account the degree to which medical-model labor management contributes to excess postpartum bleeding via oxytocin use, instrumental vaginal delivery, and episiotomy. The gap would probably disappear were all women given optimal care. There is also no evidence that active management of third stage improves outcomes over treating excessive bleeding when it occurs while at the same time, it introduces the possibility of iatrogenic harm. For example, is it really a good idea to pull on the umbilical cord when you don't know how well the other end is attached, i.e., velamentous insertion or placenta accreta?"



Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. [Medline entry]
Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D
Lancet 1998 Mar 7;351(9104):693-9

INTERPRETATION: Active management of the third stage reduces the risk of PPH, whatever the woman's posture, even when midwives are familiar with both approaches. We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage.
The Hinchingbrooke randomised controlled trial labour policy cards - Policies for the management of the third stage of labour in the Hinchingbrooke randomised controlled trial.

The Hinchingbrooke Third Stage trial. What are the implications for practice?
Rogers J, Wood J
Pract Midwife 1999 Feb;2(2):35-7


Please, please would you read the Bristol trial again? I would replace the term 'expressed reservations' with 'serious methodological flaws'. (For anyone who hasn't read this paper, it is considered by many people I know as a prime example of how you can bias research to say anything you like). Huntingdon Hospital, England, did a terrific third stage trial about 4 years ago which came up with entirely conflicting results - they showed physiological third stage to be safer than synt. (pitocin) and controlled cord traction.


One of the abstracts from the recent society of Perinatal Obstetricians meeting (reference provided upon request) described a randomized trial of physiologic management of third stage (no intervention) vs. pitocin with birth of baby and controlled cord traction (Brandt Andrews maneuver).

Results indicated less retained placenta, lower ebl, less pph, less manual removal of placenta with routine pitocin and controlled cord traction.


I always tell people who recite this study to remember three points:

1. That slight decrease in average blood loss is not a clinically important amount.

2 The study had two points in the protocol; Controlled Cord Traction during the first strong post-partum contraction (NOT uterine massage), and AN INJECTION OF PITOCIN/SYNTOCINON WITHIN 15 SECONDS OF BIRTH -- preferably with the birth of the shoulders!
THIS STUDY IS NOT APPLICABLE UNLESS THE PITOCIN ROUTINE IS FOLLOWED!

3. The decrease in length of third stage and the slight reduction in average loss was balanced by a higher incidence of hemorrhaging and of manual removal.

Many of those who cite this research seem to have only read the headlines, and not the rest of the study (or even abstracts of the study)

I think an argument can be made that an attentive third stage is a good idea (the midwife being ready to move on the placenta at the first moments of separation), but the benefits of routine CCT without the additional protocol of routine oxytoxics, are not yet proved.

People hold strong opinions about third-stage management. I think that maternal wishes should be a strong factor in midwife opinions, and if the woman desires a physiological third stage her midwife should honor her wishes! Obviously, the midwife will intervene if there's a problem, but outside of that eventuality, the woman is in charge.



Nipple Stimulation



A simple alternative to parenteral oxytocics for the third stage of labor.
Irons DW, Sriskandabalan P, Bullough CH
Int J Gynaecol Obstet 1994 Jul;46(1):15-8

Nipple stimulation showed similar results to syntometrine.


Management of the third stage of labor with nipple stimulation.
Kim YM, Tejani N, Chayen B, Verma UL
J Reprod Med 1986 Nov;31(11):1033-4

Nipple stimulation was found to be a safe alternative to oxytocin in the management of the third stage of labor.



Placenta Protocols



Article on Third Stage by Victoria, Australia Midwives


My protocols require that I consult if the placenta is not out by 30 minutes after the baby is born. I wait patiently for about 20 minutes. Then I drain the cord. Then I try a little gentle fundal massage. Somewhere around 15-20 minutes after the baby I have the mom start doing some visualization about the placenta sliding off the wall of the uterus and slipping out. At 25 minutes I use IM or IV Pitocin (depending on if she already has an IV or not). Finally, at 30 minutes I consult. Usually these other measures will get the placenta before then. I also feel comfortable sliding one or two fingers into the vagina to see if I can feel the placenta sitting there in the cervix. If it is, I have the mom push it out while I apply gentle cord traction. I would estimate that I've only had to consult for "prolonged" 3rd stage about 4 or 5 times in the last 1000 births.


Homebirth midwives should have an expectant management policy with the placenta and the expectation is that the mother will birth her placenta just fine unless proven differently.  Hurrying the placenta and interfering with the bonding by doing BPs is a recipe to "create what you fear".  The women that I work with have a 30 minute rule for 3rd stage---no mention of the placenta until 30 mins has elapsed, no phone calls to family.  Mother and baby spend 30 mins undisturbed (falling in love, exuding hormones, kept warm, lying down, skin to skin).  We observe the mother's face for signs of wellness---are her eyes bright and shining?  does she have that pretty p.p. flush??  is she smiling??

When left alone, the mother almost always says right at the 30 min mark  "I have to push again"  and we have the bowl ready for the placenta.  If you think about it, the uterus is probably contracting every 3 mins so it takes about 10 of those tightenings to spontaneously birth a placenta.

If the mother is having clotting problems or bleeding too much she will look pale and be asking someone else to hold her baby.  These are signs to get on it and find out what is wrong but these cases are extremely rare with a physiological 3rd stage.  That grand multip uterus that pushes a baby out efficiently will also push out a placenta.


We were discussing pitocin and saline in the cord to bring about separation of the placenta. She mentioned she uses saline (10ccs, I think) occasionally and the placenta has always followed within a few minutes. I thought it interesting enough to bring to the list.


As for when I inject Saline into the cord, I do it when usual methods to deliver the placenta have failed., and either the Mom or I feel the need to get on with things and get everything over so she can give her undivided attention to the baby and have me stop futzing with the cord, etc. Usually by this point there is partial separation, and it just needs a little nudge to completely separate. Of course if bleeding seems heavy I don't wait . Hope this answers your questions.



Editor's Note: When you inject anything into the cord, it seems most likely that it is going into the vein, which is then dumping the injected substance directly into the baby, who is going to have to deal with whatever it is, filter it and then return small amounts back to the placenta through the arteries.  Yes?

Most/many of us with a non-pharmaceutical view of third stage see it as a three step process;

1: separation from the uterine wall;

2: expulsion (often, but not always with the separation contraction) into the lower uterine segment -- or upper vagina;

3: expression (by mom or attendant) from the vagina.

A partially separated placenta will allow bleeding; as will a fully separated placenta which is still in the upper uterus. We have to get these out right away.

A placenta which is sitting in the lower segment with a tightly contracted uterus on top of it, isn't causing any problems and (though we will watch it carefully) we can wait till stronger contractions expel it, or mom feels up to pushing it out or standing to deliver, or we give a little cord traction and pull it out.

Controlled cord traction/modified Brandt-Andrews - as used in this part of the world -- is designed to bypass this second phase and bring the placenta from the upper uterus to the introitus at the moment of separation. Advantages are that it finishes third stage more quickly; and avoids leaving a separated placenta in the upper uterus and it MIGHT avoid partial separation and entrapment. ( Few in this region use pitocin with the shoulders -- most use it post placenta -- I always wonder how this affects the results since the studies on active management have all been done with pitocin/methergine etc with the shoulders).

Disadvantages are that it might CAUSE partial separation and profuse bleeding; it may leave portions of placenta or membranes in the upper uterus; and some folks seem to pull the cords off pretty regularly and then feel compelled to do a manual extraction[Grin]..

I think it is seldom necessary; though usually causes no great harm.

Most of us use CCT/Brandt-Andrews here only in the case of partial separation; not as a routine. We figure a little more time waiting for the placenta (if all is well), balances out with less frequent episodes of hemorrhaging and trapped placentas.

Saline in the cord to speed separation is an interesting trick -- I assume the theory is it would work by forcing fluid through the placental villi? I found a number of very old references for saline (or warm water) injections into the cord -- a think glucose is mentioned also.

Would anyone worry about embolism?

Also.... I think speed of delivering the shoulders, may influence third stage -- taking time with the shoulders giving us a better separation and expulsion phase. Comments?

(Or maybe it's another thesis project for someone! -===== Does time from delivery of head to delivery of body affect the timing of placental separation? I'll bet it would be easy to set up, if you could get agreement to expectant third stage management).


Most of my births have EBL of <100 ml. I frequently tell the moms that lots of women have heavier periods! A lot of moms don't even have the amount of blood to fill a couple 4x4s. Some, of course, have a greater blood loss, but > 500 ml is really rare for me. If most of your births have EBL > 500 I would suggest that you look at 3rd stage management.

I freely admit that I am aggressive in getting those placentas out. The studies I have read indicate that aggressive third stage management results in less blood loss, and less incidence of PPH.

For many of you on this list, what I am going to post will sound like anathema to you. However, I read stuff all the time that makes my hair curl...and that is one of the benefits of this list....that we share a variety of practice styles.

Once the baby is born onto mom's belly, I dry, stimulate, get parents hands on (if they haven't helped birth their baby ) and eventually clamp the cord. I then turn my attention to mom and baby. I spent 10 years giving pitocin after the placenta....then I changed to giving pitocin after the baby, but before the placenta. I think this has drastically decreased the blood loss, and studies confirm this. Sometimes I forget to give pit at all.

After the dust settles, I put one hand suprapubically, and one hand on the cord. Every now and then I do Brandt-Andrews maneuver (suprapubic pressure while doing controlled cord traction...if the placenta has separated, the cord will not retract when doing suprapubic pressure directed upward. If the placenta is still attached, the cord will retract.)

If the cord retracts, I wait. If the cord does not retract, and/or there is a gush of blood, I do controlled cord traction while guarding the fundus. I have evulsed a cord two or three times in 1100 births, but they were velamentous or marginal insertions. I rarely have retained placentas, manual removals or PPH. The women do not seem to mind what I do in third stage.

I believe that a separated, but undelivered, placenta which sits in the uterus collects a lot of blood behind it. Hemorrhage may occur with no external signs. Maternal vital signs do not change until mom is hemostatically compromised, and may be normal even in the face of significant hemorrhage. The uterus cannot clamp down until the placenta delivers. 500 ml is by definition, a postpartum hemorrhage.


I have found that if you take one finger and gently follow the cord up you will find the placenta sitting right at the cervix nearly every time you have had a separation gush. And I never pull on a placenta. There is a difference in gentle cord traction after separation.


My feelings (for what they're worth) about third stage management is that if you've messed around with the physiological processes of labour at all during the first and second stages, then you cant afford not to for the third too.

I work in a fairly interventive hospital setting where women may often use opioid analgesia or have epidurals or ivs or augmentation or be poked and prodded in one way or another... For these women I think an actively managed third stage is probably the safest option.

That here means an IM injection of Syntometrine (mixture of syntocinon (pit.) and ergometrine) with the birth of the anterior shoulder of the babe if you're following the textbook, or following the birth of the babe and cessation of cord pulsation if you're sneaky like me... Then clamping and cutting cord, then awaiting firm contraction of the uterus or signs of separation (whichever you prefer). Then applying 'Controlled Cord Traction' (how Firmly Comforting and Solidly Reassuring those words sound...) whilst 'guarding 'the uterus. And finally massaging the uterus to expel any clots post delivery. Blood loss is generally minimal (although pph's still happen), An interventive end to an interventive labour; not the ideal but my current reality

I am confused by the logic of giving 'pit' post placental delivery. Surely if you have delivered the third stage and the woman's uterus is well contracted, you have passed the most risky time (and if you are still using CCT etc. and fiddling... working against physiology in all ways you are going to provoke the haemorrhage that is going to require the pit. 'cure')??

For non-active management. I have been taught to not clamp and cut the cord at all, and sit back on my heels and wait: No pulling. No massaging. No 'fundus fiddling'. HOWEVER... I sadly admit that i am still waiting to conduct a 'physiological' third stage... and as I only witnessed one during my training I cant feel myself really qualified to do so. This is the great flaw of the 'Bristol Third Stage Trial' (always quoted as gospel here). The midwives were expected to make a sudden switch to a procedure with which they were not familiar and inevitably had bad results. Plus the women allocated to the non interventive group may have undergone medical, interventive labours and thus already had their normal physiology compromised...


I'm curious because first of all we rarely see a woman with 500cc blood loss or less. Is it something in the water here in So. Cal. or have others noticed this as well?


Well, two things come to mind... First.. silly question.. but blood loss is hard to estimate without double checking a few times and is it possible you are seeing less bleeding than you think? We rarely see a woman over 500cc...

I've conducted blood loss estimation workshops both with real blood both human and cow) -- it's the only good way to learn. Every time we do one, there are a few highly experienced midwives who discover that they consistently over-estimate! (and one in particular was SO relieved! She was able to cut down her pitocin use drastically after she took a workshop[Grin]).

Second...I also think that hurrying the placenta encourages blood loss - -clamping the cord before it's flat (under ten minutes or so), touching the fundus before separation (causing uncoordinated contractions), and trying to extract the placenta before it has been expelled into the lower uterine segment, all play a factor...

I'm not too impressed with herbs either and find that broad handed - even pressured massage will contract a uterus far more quickly than IM pitocin (with both hands and fingers spread wide -- trying to push the uterus into itself -- sort of like gathering up a broad lump of dough into a ball. This is a different massage than many texts show. I wish I could demonstrate; I don't know how clearly it comes across in words).

Most uteri will respond immediately -- well before the pit could have effect. I've drawn it up a few times, but haven't had to use pit in years since I learned this..

Used to give shepherd's purse at every birth.. hardly anyone bled.. Then stopped giving it and still find hardly anyone bleeds ( ...more than we like to see). I think it's good to discuss this frequently. We are all looking for new tips and tricks of the trade...


We are doing hands-off cord and fundus til the mother says she's having a contraction. Used to monitor the uterus and we'd tell the mom when she was contracting and to push with it, all the while holding the cord like a leash. Makes for a much more relaxed immediate postpartum to just focus on the baby/mom's comfort and wait patiently for the mom to initiate the birth of the placenta. Seems like the separation/placenta delivery contrx. come spaced depending on the spacing of 2nd stage contrx. Takes longer if q5 than if q2. If I do check for level of the fundus, I do it very lightly, no massage, just to note location, after the mom has had a contrx or two. We still do some cord traction as the mom is pushing, but a lighter touch than in the past. (And no, I've never pulled off a cord, but probably will some day).

Placentas take longer - used to have most out within 10-15 min., now it is more like 15-30 min. with some longer. Just did a birth for a FP doc's wife and I could see he was beginning to wonder when placenta was still in >30 min., but it spontaneously birthed at 42 min., no cord traction, minimal blood loss.


I have attended about the same number of births as you, and I have NEVER used pitocin on a woman before, during or after the birth of the placenta. I have on rare occasion used herbs, and I had a package of methergine tablets once, but those are long gone having used most of them on a woman with a late PPH, but I find myself using herbs much less often than I did years ago, and the few times I gave a woman a methergine tablet, the bleeding stopped within minutes of swallowing.....I doubt that the meth worked that fast!

I would classify my "management" of third stage as being semi-active. I do feel comfortable requesting that the mom push a placenta out when I have signs that it has separated, and I will use a traction on the cord while the mom pushes. I have had one cord fall off, and before I handled retained placentas myself (about the last 5 years, I've removed two since....both entrapped placentas) I transferred 4 times for retained placentas (one lady twice!!!) I have never had a PPH, apart from those partially retained placentas, that I wasn't able to get under control. I very seldom have a PPH at all.

I'd like to think that it's because of my superior skills and the fact that all my clients have perfect lifestyles and diets, but I know these things are not true! I take smoking mothers, I have mom's with very poor diets, very young girls, grand-multips, etc.......many women that would be expected to have poor third stage outcome. And as for my skills, I'm just a normal midwife who makes mistakes sometimes and poor judgment on occasion......I think human would describe me well! :-)


I don't agree with the "quick, get it over with" way that most midwives treat the third stage.  I believe it comes out of the medical model where there is a mistrust of the birth process and a woman's body.  When a woman has experienced the pain of dilation and pushing and we know those are healthy, normal passages--why do we need to save her from pain that accompanies the birth of the placenta??  So many things that we were taught would be "helpful" have been proven to be wrong---treating the umbilical cord comes to mind.  It's possible that "helping" to get the placenta out quickly could be proven to be harmful. There certainly are reports of cases of uterine prolapse with gentle cord traction, not to mention pulling off the umbilical cord.  After the fact, the practitioner always proclaims how gently they were pulling.  I find it interesting that the unassisted birth groups think that I am horribly aggressive for expecting the placenta to come out in around 30 mins. They have healthy, normal 3rd stages that can last for days.   Patience and guarding the normal are the hallmarks of midwifery.  The influence of the medical model must be weighed in everything we do.


I have learned to be more assertive.  In the last 3 years, or so, my clients' placentas have delivered quite a bit quicker.  Usually in 5-10 minutes.  The reason: upon noting the signs that the placenta has released I encourage the mom to push the placenta out.  I used to wait until she felt more crampy.  I used to wait so I wouldn't interfere with her time w/ her newborn.  I used to wait because I didn't want to be aggressive and take control over a natural function and cause a problem.  I have learned that encouraging the placenta to come, when it has released, actually helps the things I was trying to accomplish by waiting!

Minutes after the birth the cervix is nice and open and allows the placenta to come easily.  The woman is usually  glad to get it out/over with.  She is happy to have me not sitting and waiting on her placenta.  She can concentrate more fully on her baby and on nursing without me asking if she is having a contraction or if she feels like pushing the placenta out.  I am glad that I can assess her blood loss and not be at a stopping point when there is clean up and charting to do.

We are taught what the 3 signs are that the placenta has detached, but then we are sometimes taught that midwives shouldn't do anything with that info.  Just as holding a stubborn rim of cervix up isn't aggressive when it is warranted, I've learned that it isn't an aggressive action to help a mother with the last stage of her birth.


Placental Delivery on the Toilet

Lift the seat of the toilet and place an open plastic trash bag across the toilet.

I usually will just slip the cord (with kelly) under the seat. When the placenta comes the trapped cord will keep it from going too far... I just lift it out when we're ready to chuck the thing -- or whatever they're gonna do with it..


I usually will put a chux underneath the toilet seat. It's easier to examine the placenta and to estimate blood loss. Plus I think the mom feels like it's a little cleaner. I also will do this if the mom chooses to deliver sitting on the toilet. This way nobody is worried that baby or placenta will get dropped in the toilet.


Drinking Warm Fluids for Placental Problems

Y'all know what the farmers do for retained placentas in their cows?   They give them oxytocin and a bucket of warm water.

I do remember old-time midwives having moms drink a LARGE glass of water if the placenta was delayed. They insisted it would help bring the afterbirth.

I wondered if it might fight dehydration (and thus make the body work more efficiently) or else to make the bladder full enough to cause uterine cramps.. .but there was a recent research blurb that causing over-hydration (with IV fluids) resulted in stronger contractions and a more rapid birth. The effect looked equal to pitocin!  Very interesting if the cattlemen and the researchers might have both stumbled on some simple physiological method to increase uterine contraction power.

If further research upholds the idea, then over-hydrating with IVs is pretty easy to do (not without risk though). But I can't imagine over-hydrating with oral liquids would be dangerous -- it might not even be possible?


I think the key is to get warm fluids into the digestive tract, which causes the intestines to start moving it along, which causes sympathetic contractions in the uterus.

That's why IV hydration doesn't do it . . . it bypasses the digestive tract.



Third Stage for Waterbirth



I've been having some really beautiful, peaceful births with moms and dad catching their own babies and sitting back.  My assistant and I have especially made a point of being quiet and in the background right as the baby is being born and afterwards.

I've been noticing the grimacing and wincing that occurs, I believe, with placental separation, but I haven't been seeing any spontaneous placenta births.  It appears that what happens is the placenta appears to separate (with the tell tale gush), but nearly all my moms are in the tub still at this point, sitting oohing and kissing on their babes. After quite awhile of them looking uncomfortable and "ready to be done with it", my assistant has helped birth the placenta with some cord traction.

Does anyone see regular spontaneous placenta births in the water after birth?  I'd really like third stage to remain mother-led, as the birth is.  I'm just wondering what, if anything, could be done to help facilitate the birth better.  Is it because the mother is sitting?  What about kneeling?


Separation and expulsion are two different processes. The placenta "may" separate from the uterus after only five or ten minutes. From there it spontaneously moves through a series of small contractions to the upper vagina. There's generally no harm allowing the placenta to descend through the natural process. The uterus is strongly contracted and there isn't any additional bleeding (the placenta is in the vagina, or lower uterus; its' harmless there; it isn't holding blood vessels open)

When the placenta descends enough to put pressure on the rectum, the moms will often feel uncomfortable and let you know that "something's happening". Sometimes they will just spontaneously push. Or you can see the cord has come "way down" -- or can see the membranes, or bulge.

Here's a common time table:

We will often see possible signs of detachment within about ten minutes of birth.

But... if we allow a "mother led" third stage, the placenta expulsion stage seems to happen at just about 20 to 30 minutes after birth.

We can make it happen faster sometimes, by changing moms position. And we can certainly often make it happen quickly by just pull the thing out at any time.

But I don't like to intervene unless there's a good reason.

Twenty minutes -- a half hour -- goes by very fast if moms are busy loving their babies. The placenta's often ready to come, just about the time many moms are ready to get a change of clothes -- or want to get out of the tub.

There are NO absolute rules -- and NO routines which apply to all women. But -- in general -- with waterbirths, we generally expect to get mom out of the water when it's getting close to half an hour after birth (things have settled down, and the water is often cooling). "As a general rule", moms first move to a chair beside the tub. We have the placenta chux ready, because shortly after mom stands up to get into the chair, she often feels the placenta sliding down.

When waterbirth first became popularized, there was a thought that the placenta shouldn't be delivered in the water. We were supposed to rush them out before the placenta came. But because i've always done "mother led third stage" it didn't seem to be an issue though. The moms almost always were ready to leave the water before the placentas came. And our clocks almost always showed this was about a half hour after birth (give or take ten minutes).

If you read the older midwifery texts -- and the older OB texts -- they all say to expect the placenta comes at about 20 minutes to half an hour -- "sometimes longer".

They didn't have the newer understanding that placenta's may often separate more quickly than this.  But they did have the age-old observation that it usually took about a half hour before the placenta "appeared".

I'm still comfortable viewing the third stage as a two-part process of: 1. separation and 2. expulsion.

And so far, I'm still willing to let the process occur in it's natural time -- while being ready to intervene at any point if needed.

It's an individual decision though  ---- one we all need to work out with our clients.



Brandt-Andrews Tip



I will do a Brandt-Andrews to see if the cord pulls up. If it doesn't, I will do light CCT with mom giving a push. I do not guard the uterus. In fact other than the suprapubic pressure during Brandt-Andrews, I don't like to touch the abdomen while the placenta is still in. Don't know why, but I don't.


When I was interning, one thing I loved was placentas. They wanted them out right away, and my confidence in knowing when it was detached grew tremendously. For the most part, aside from watching for cord lengthening and a separation gush (which seems to be absent a lot with a Schultz placenta) we used Brandt-Andrews to be sure it was detached. Then we kind of stretched out the lower segment of the uterus (like guarding but stronger) and guided the placenta out with the cord. We didn't use a clamp on the cord, just our gloved hand.

One little trick I was taught was that if you have a full bladder, you know how the uterus goes off to one side - well if you do Brandt-Andrews then it acts as though it is not detached. If you take both hands and center the uterus over the pubic bone, you get a "correct" reading.

I really love this, because I have sat through so much anxious waiting, checking to see if the uterus was filling with blood, sometimes the cervix would start to close down and the placenta didn't want to come, and everyone in the room was focused on the placenta, rather than the baby.

When I get them out nice and quick the mood in the room is so much nicer. The two I've had since I was back where the placenta didn't deliver within the first ten minutes, didn't want to let it out - it was detached.

By the way, we were taught to really vigorously massage the uterus there to expel clots etc. After some discussion on the list about how gentle massage works just as well, I've been doing this, and at the last birth I was at (where mother didn't want to let the placenta out) I went to massage gently and wow! Those clots popped right out! Then, not totally trusting that the gentle massage was getting them all, I worked harder at it, and no more came. I was really pleased to see how well those clots popped out with gentle massage.

So, I guess I do active management, but without the pit. I've seen MUCH less bleeding this way - but the other variable in these births is no directed pushing in 2nd stage, which we've discussed before.



Partial Separation



In my midwifery training we were taught to never massage a uterus UNTIL the placenta is out.


I was taught during my training to NEVER massage the uterus, that it will cause the bleeding that it is suppose to prevent. I must say, we hardly ever saw a bleed.


I too was taught hands off the uterus before separation to prevent a partial separation.

At the hospital where I interned, the more experienced midwives can massage a partially separated placenta off the wall of the uterus, sort of an external manual removal. What we are taught has a great deal to do with the skill-level of our midwifery community, and our ability to maintain sterility (plenty of midwives are taught never to do an internal).

Who knows what manual skills have been lost, or are known only to communities of midwives outside our sphere of communication? I have heard a few amazing manual dilation stories that snatched birth back from the jaws of c-section, but have yet to find anyone to teach me.



Retained Placenta



Intraumbilical injection of uterotonics for retained placenta.
Habek D, Franicevi? D.
Int J Gynaecol Obstet. 2007 Nov;99(2):105-9. Epub 2007 Jul 2.

CONCLUSION: The intraumbilical injection of uterotonics is a noninvasive, effective, and clinically safe method of shortening the third stage of labor in women with retained placentas.

[NOTE - This is injected into the umbilical VEIN! which is the large one, compared to the two arteries.  And yes, it's after clamping!]



From Henci Goer,  WINNER of ACNM's "Best Book of the Year" award! Optimal Care in Childbirth: The Case for a Physiologic Approach by Henci Goer & Amy Romano  is available at optimalcareinchildbirth.com :

I have a couple of articles agreeing that distraction may be harmful in 3rd stage: "Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study The "psychophysiology" article discusses the importance of an undisturbed atmosphere and the need for the woman to understand that the birth isn't over until the placenta is delivered along with recommendations for midwifery care strategies. As a side note, I remember decades ago there was a birth film that made the point that in English, the placenta is called the "afterbirth," implying that the significant event was the birth of the baby, but in Spanish (Mexico? South America in general?) traditional cultures it is called the "companion" and that unlike here, where everyone relaxes after the baby comes out, relaxation occurs only after the placenta is delivered and the uterus contracts.

I recently learned of a practice using Cytotec for retained placenta.  Is anyone else familiar with this use?


Yes, I have seen Cytotec work beautifully with partially separated placentas . . . blood was streaming out, so I administered Cytotec rectally, and the placenta was out and bleeding stopped very quickly.  One of the benefits of Cytotec with PPH is that it helps keep the uterus very well clamped in the hours immediately after birth, thereby reducing additional "normal" blood loss that might be too much for a mom who's had any kind of PPH.


In our farming community,, when the ladies don't deliver placenta within a half hour, the men have them drink a good glass of warm water.


I tried this today on a client, and the placenta came out easily in about 7 minutes.  Her contractions had been every 6 -8 minutes up until the last few contractions and I thought if  she continued to contract that far apart after the birth  we might have to wait a long time for the placenta.  Thanks for the great idea!


I was taught to ask the woman to blow into a closed fist.  This seems to contract the lower abdominal muscles in a way that may help the placenta come out more readily than standard "pushing" techniques.


Where I trained, the midwife would observe for a rise in the fundus, and then provide continuous pressure on the fundus, kinda massaging the placenta out. She would feel the placenta under her hands and smush the placenta neatly out the vagina into the student's waiting hands. The times I saw it, that was the end of it and there was no more bleeding.


When you did this, did you use one hand and just "squeeze" the uterus?  I'm thinking of fingers on the posterior side of the uterus, and thumb in front. Does that sound right?  This must sound terrible to anyone who hasn't seen it, but it worked slick as a whistle.


I don't remember anything more than just pushing on the fundus in a smooth, steady motion, downward.


1. Retained (or delayed) placentas - Angelica tincture (angelica atropurpurea) Tried all my usual tricks, emptying bladder, squatting, warm water, draining the cord, finally cord traction did it. I am a big fan of getting the placenta out right away (for homebirth midwives that means 10-15 minutes) it reduces postpartum blood loss, the pp Hgb is higher and moms feel better afterwards.


Sometimes we would give 30u Pit into one of the vessels of the umbilical cord, with good results for separating a stubborn placenta.

I've read a lot about the effectiveness of using angelica for separating the placenta, and I'm interested in hearing any comments.


Can someone explain why injecting Pit into the cord works? Is it because the vessel carries the pit directly to the mother's blood stream? Does it matter which blood vessel into which it is injected? What if the umbilical cord has stopped pulsating? (which would probably indicate separation, I know.)

We have used Angelica for several years with good results. I have only ever seen one manual removal, and that was the one I had to do myself. I think the Angelica was probably working because I was very nervous, (I was alone - my partner had to run off to the next birth) and I don't know if I actually separated that placenta myself, or if the angelica was working by then. Probably a combination of both. At her next birth she lived in another part of the state and had a different midwife - one with MUCH more experience than me (over 3000 births) and I heard that the same thing happened - had to have a manual removal, with large blood loss. :( At least I don't feel so guilty, that the first time was somehow my fault that it happened.


I use a tea made with angelica, black and blue cohosh, ginger, raspberry, and lots of honey. Every mom gets this unless she pushes the placenta out before we can get her to drink it. Some moms love it, others would rather get up and squat to get the placenta so they don't have to drink it! I've also made a tincture of this for those fast births with no time to make tea. I do think that angelica helps but it also just may be the warm tea with honey.


I think the success I've had comes from a powerful belief in the ability of a woman to have a baby, get the placenta out and then stop bleeding.....even if she's exhausted.

I won't deny that on a few occasions I wish I had had pitocin, but I didn't, so I had to use my mind and my hands to get the PPH stopped. I have no doubt that had I been trained to use pitocin, I would feel more comfortable using it.......I've noticed this with the few midwives in Nevada trained in Texas midwifery schools. And of course, since it's illegal for me to care any drugs, I have acquired and used drugs only on the rarest occasions.


There are several kinds of retained placentas.  There's the still attached, (no bleeding, uterus is not getting rid of it), type.  I think that you can wait for a good long time for these.  If you are not in the hospital, that is.  (Time limits there.) Some of these will be accreta and need some medical intervention.  Most come out.  Lots of methods to do this.  One of my friends always gave oxygen, some gave pitocin in the cord, some give piton IM, some like to squat the woman.  There's featherin'.  (Only have heard about this)  Tickle the woman under her nose with a feather.  Have also heard about other ways to get the woman to sneeze.  Breastfeeding is my personal favorite.

The list is long and creative.

There's the placenta that is loose, held in uterus by closed cervix.  I had two of these in one night.  Rather, I had one and my partner and the back-up had the other after a forceps delivery.  We took both to the OR and gave general anesthesia.  Geeze, that was weird.

Another is the placenta sitting somewhere in the canal, with some amount of bleeding behind it.  Students who are shy with cord traction can sit and watch these for a while, I tend to be aggressive with them.  If cord traction seems about to break the cord, I follow it up and grab the placenta.

I have heard a few good OBs, including a MFM, say that an inverted uterus is usually not a result of too aggressive cord traction, it just happens.  I want very much to believe this, although I still guard the uterus while I'm pulling on the cord.

Then, there's the placenta that is partially retained with steady bleeding. Partial accreta or pieces left.  This takes some quick action.


I have waited 24 hrs for a placenta- mom was stable, no raising of the fundal height, no bleeding, zero bleeding and no the placenta was not just sitting in her vagina.   The baby before the one I caught and all the ones after had the same 24 hr delay. Mom's sister had a manual removal in hospital with baby#1 and considerable bleeding.  From then on out never went to the hospital again; she also had 24 hr placentas. I know the midwife in attendance of the first birth this woman had and she didn't tell me about this until after the experience-- so what I do know is that there are at least 5 other midwives with the same experience.

I have also done some research, and in Italy they do conservative management of placenta acreta- ultrasounds and abx- I am not sure that this is acreta but for what ever reason that these women have retained placenta, hey are fine and in good health which is our goal-- we found that trimming the cord closer to mom's body kept it out of the toilet and we left it unclamped in case draining would help it release better-- she didn't have after contractions but the fundus was firm.

MY thinking is why are we doing anything if mom is stable? you could add abx but any other way to manually remove  puts mom in danger- destabilizes her.

I have had another mom whose placenta was very unusual-- probably 3-4 inches thick with  some of the cord imbedded in the body of the placenta  looked like a jello mold with a cord in it normal insertion looked like a healthy placenta other wise-- the cord stopped pulsing fairly quickly and just before that I saw what looked like a bit of a separation bleed, which made me a bit more concerned when there was no placenta after the first hr. but there was no continued bleeding; turned out after the placenta was delivered and we looked at it the bleed probably came from the cord  - one of the divisions ,that create a cotyledon had  2 sides of the cord partly torn and the only clot on the placenta.

So I have also seen 3 partial separations-- 2 were not my births, in any case , there was only one that was a very brisk bleed.  the other 2 were seeping one very slowly and the other was a slow but steady stream- I would chalk this one up to maternal exhaustion- she was up for days with sick kids before labor started- she even felt uncomfortable like maybe she needed to push the placenta out just didn't want to bother; had given her space, food and drink, baby nursing well, contractions; she peed on a chux, herbs, 1 shot of pit 1/2 hr later another shot of pit----- sent everyone out of the room except dad and baby and said your body is like a holding tank for a well, and you know if you keep the faucet on even if it is just a slow steady flow it will eventually empty the tank and before that we are getting you into the hospital- you have lost as much blood as I would expect to see with the delivery of the placenta- can't go any longer, so then she mustered the strength and sat up and could feel the pressure but really didn't want to stay up-- so we ended up holding her up in a squat my hand covering the back of her perineum and anus- thinking that she was probably also afraid that it was going to hurt her butt-- and she got more contractions and birthed the placenta-- she was so worn out that she was exhausted and really didn't want to bother with one more thing, also this was their last baby- they were planning on having no more and it is her 3rd boy not the girl she was hoping for.

In fact, in all the partially retained placentas there was something intense in the emotional aspect. The brisk bleed I was just supposed to be another woman at the birth, 2 other midwives did the birth; I saw the bleeding start and no one was paying attention- mom wasn't having contractions- I said something to one of the midwives to take a look-- and let it go, she said to mom if she felt any pressure no so waiting- but this is too much blood and I say this is at least 2 cups here...... so they get mom up and she passes out.... long story but basically we are in a car driving to the hospital because no ambulance service to this property. midwife at her head and one driving- they wanted me to give advice but I ended up at the wrong end or maybe their intention... anyway I was holding the uterus from the out side and she was still pouring blood- and I was praying for this gal and trying to talk to her, and she kept passing out, when she passed out blood just poured, uterus was firm when she was awake, I started joking with her, trying to take the stress down a notch or 2 and I told her I was going to see if I could get ahold of the edge of the placenta- and some jokes with it and she laughed, but she still went out again and i reached in and scooped the placenta out, her cervix was open as if it were complete and pushing a baby out-- when she was out and closed when she was awake so I grabbed the cervix when she was awake and held it tightly shut and compressed from the top-- and she stopped bleeding, and the uterus made a tight ball and she didn't pass out again wheeled her in to the hospital and she was fine from then on out..... long back story but basically she was on the phone to her boyfriend before they wheeled her completely into the room- telling him how she almost died...now he needed to come to the hospital and be with her-- he was thrown out of the hospital 2x and not allowed to come back... so these are not complete stories by any means I am sure that there are things I forgot to talk about or got something out of order- my always excellent memory is not so excellent anymore-- but I guess the point of telling the partial retained stories was to let you know why I think no big deal for a fully retained placenta. 


[from ob-gyn-l]

Then there is the case we just had of "Percreta" that has a real high chance of recurrence. This patient had a percreta that involved the bladder "amazing cystoscopy". The diagnosis was made early and she was delivered by a true classical C/S. the cord was tied close to the placenta and the placenta was never touched during the case. blood loss < 500 cc. The uterus is now involuting quite well at 3 months pp (12 wks size.)



Retained Membranes



Can anybody elaborate on dealing with possible retained membranes and eventual outcomes?  I've a mother that birthed this am and only was able to tease out a portion of the bag.  No excessive bleeding has occurred.  Fundus remains firm and involving OK for the few PP hours I stayed.  I did a sterile exploratory uterine check as best I could, and teased out a fair portion of the bag, but just feel like the rest is still stuck inside.  I've advised forcing fluids, using some Echinacea, some vitamin C, temperature checks, and to observe for any tissue passed at potty trips.

Any more suggestions?


I wouldn't treat her any differently than any other PP mom. I wouldn't do the echinacea or vit C or anything since I don't think she is at any higher risk of infection than the "usual" mom.

the membranes will come out without any fuss or bother - -probably wrapped around a clot and making an interesting little clump.

I know folks who would recommend oral methergine tabs for a few days "just to make sure", but I think if mom is upright and moving around and nursing a baby, then she is moving around enough and having strong enough contractions to empty her uterus without any additional help.

I wouldn't sweat it too much. I don't think retained membranes are a big deal. 


I agree in part.  If you have gotten most of the membranes out, the rest will pass over the next few days.  I have had a few ladies where nothing has come and I do believe that with those methergine is in order (I give 6 tablets to be taken every 5 hours, round the clock, until gone).

That being said, I will leave 2 methergine tabs with the instructions to take them if they feel they are bleeding too much, and call me. Sometimes the ladies take one and don't call me :0) and that is fine. 


Again..w/o any excessive bleeding, do you advise the Methergine one tab PO every 5 hrs x 6 doses then? (Bear in mind she only passed about a quarter of the sac immediately pp.)  What about hefty afterbirth cramps in a woman as it is?  I'd take that as a sign that her uterus is crunching down effectively for now....huh?  Is Methergine still a good idea?  She's only taken one solitary dose of IB for afterbirth cramps over the last 48 hours now.  No clots or discernible tissue have been passed.  I've warned her to observe for the next week or two as a precaution.  Mom remains afebrile and baby's doing just fine as well.


Many times "hefty afterbirth cramps" indicate something left inside.  The uterus is having to work extra hard to stay contracted. 


sometimes the membranes pass as such tiny shreds -- they roll up on themselves and stick together. Mom might not notice anything particularly unusual. 


Yes, I would still give the meth as the situation dictates such.  The craziest thing about using meth and afterpains...not unusual for the afterpains to disappear.  But, if my lady is known to have severe afterpains I 1)sit her up as soon as placenta is out (I get them comfy with a couch pillow behind all the other pillows plus arm rest pillows) 2)immediately give cal/mag, Afterease and IB.

The old doc used to tell me to give those drugs because, as he pointed out, I am leaving.  Anytime I feel I am missing even a piece of membrane I give an injection of .2 mg meth and leave 2 tabs to boot.  If it is more than a 'piece' I have them take 6 meth over the next 30 hours beginning from the first 5 hours after the injection.  Plus, all my ladies get a tea after delivery. In that tea I will put herbs that are appropriate for the birth.  With someone like her I would go heavy on the angelica (I always use a peppermint base to hide the taste of the tincture).

In the old days (before having meds) I would have such a woman take blue cohosh every 5 hours for 2-3 days pp.  I had one primip whose husband would not allow me to give her anything.  She bled HEAVY 2 wks pp and was rushed to the hospital where the doc removed a "fistful" of membranes.


Retained membranes can cause late hemorrhage.  Even a piece the size of your baby fingernail.  It can cause PAIN and it can lead to infection.  It can also cause nothing.  I am one of the midwives who uses methergine tabs 1 q 6 hrs for a week or until the membranes pass.  I have the mom investigate clots to look for the retained piece.  In one case a gal had a teeeny piece and it was hurting until I used a speculum and ring forceps to grab this from her os.  She immediately felt better.  So it can be a real big deal, and requires close attn. 


i always have them pee in a strainer that way we don't miss them when they do come out.


Yeah, but by that first night, all hefty cramps had subsided--esp. after her single dose of IB.  Her bleeding is quite small, rubia, and no clots or tissue passed, unless she's not so observant of tiny shreds as Sandra mentioned by trying to catch via a strainer.  I personally don't feel that's a good idea for Mom's mindset--trying to "catch" something that might never appear, huh?  This is a fifth time mom, BTW.  Her uterus might very well be behaving for now, staying low and firm as of yesterday when I did a followup visit, and I'll continue to pray that it remains as such.  She's very compliant w/the nothing strenuous, excessive walking, going up/down stairs, etc.  Her parents are there helping out as well, and the FOB works out of their home for his company--yea! 


What tends to be the main reason for retained membranes?  I've only seen this a few times in my experience, once was a succenturiate lobe with excessive vag. bleeding, but the others usually either come out spontaneously, or I've been able to get all of it right there in the immediate pp period by coaxing them.  I didn't "pull" on the thinning string of this bag.  I coaxed it verrrrrry slowly until the last bit got so thin that it broke.  I feel that some portion is still stuck up inside where I cannot reach, because I could finger around inside the womb and feel something in there.  I am almost certain something is still left inside.  I also couldn't account for all the sac once I laid it out to examine.  There were areas not accounted for. BTW--the baby was almost born in the caul.  I pricked it once it reached three inches outside the mom's vagina.  Baby was born over an intact perineum with a semi-tight nuchal cord around her neck and across her chest and leg and I had mother push her out through the cord because I couldn't slip it off, but didn't feel any need to reduce it.  Her Apgars were a fine 9 & 9. The umbilical cord appeared to not have any oddball blood vessels trailing away.  The largest portion of sac that I teased out was attached it seemed to the lowest segment of the cord and placenta.

What's with these hateful membranes anyway? 


Placental site of attachment is the most likely cause of trouble with membranes. 


I find that asking the mom to cough sometimes helps dislodge trailing membranes very nicely. 


I keep my hands off unless her body is giving signals that she is in trouble. Nursing that baby frequently is the best tool to use to contract the uterus and encourage expulsion. I have the mom take 1,000 mg. of vitamin C q four hours. Echinacea, 10-20 drops 2 X per day. Nurse. She must stay down, take her temp. 2 X/ day. More frequently if she feels feverish, cold hot flashes. Watch the lochial flow for character, quantity, odor. Nurse. Have her keep anything she expels in a plastic bag in the refrig.. Not on a paper towel, tissue sticks to paper towels. Nurse. Have her squat over a towel before using the bathroom or cover the seat with a towel to catch anything. The membranes may be in a clot. Should be checked. B&B if she is not having firm contx. with, you guessed it, nursing! She needs to be well aware of uterine tone, tenderness and placement. All of this information is put together in handout form and left with mom's who have any retained anything! I also leave meth. just in case. Let her know that when she passes the fragments, they may smell, and she may have some strong cont. to re-dilate that cx. to let them pass. 


It's kind of fun to see the wide range we have in our beliefs about - -and treatments for -- retained membranes! All the way from "ignore it unless there are problems" to "have mom use a strainer when she pees".

I wonder if outcomes are any different with the differing approaches?

I'm of the "ignore it" extreme. Have never ever seen a problem (such as infection, delayed hemorrhage, painful afterpains, etc. etc.).



Postpartum Hemorrhage Protocol



See also:  Prenatal Nutrition/Herbs or Vitamins for Anemia


ALSO updated syllabus (.pdf) on postpartum hemorrhage [Powerpoint Presentation]


OB Hemorrhage - OB Hemorrhage Protocol Tools from CMQCC - California Maternal Quality Care Collaborative


My protocols on pph involve: getting placenta out if in, nipple stim, checking bladder status, acupuncture on Spleen 1, use of herbs as above , bimanual compression, and use of antihemorrhagics, usually in that order.


I use shepherd's purse, black and blue cohosh, pitocin and methergine (IM), and nipple stim (preferably with baby's help). I have used placenta for pph, too. I am reasonably active about expressing clots, as well. I haven't really used ice supra-pubically, though


Hemorrhages need to be controlled quickly and expediently. Pit, herbs, bi-manual compression, or manual extraction.


Big Toe Stick to Stop Postpartum Hemorrhage


Make a lancet (PKU lancet) available along with your pit and such. If a lady bleeds find the point of intersection if you would draw a line straight down from her outer toenail on her big toe(either one will do) and another line straight out from the bottom(horizontal) of the nail as well. Just a pin point below the intersect point....poke her....a good steady jab


You are describing an acupuncture point for prevention of hemorrhage. The correct location is: On the MEDIAL side (away from other toes) of the great toe, just posterior to the proximal (toward the head, not toward the end of the toe) corner of the nail. The point is known as Spleen 1 and is an empirical point for uterine bleeding. The treatment is to prick the point with a lancet to extract a drop of blood. If it is going to work, it will work immediately. The point on the lateral side (inside) is known as Liver 1. It is located on the lateral side of the dorsum of the terminal phalanx of the great toe, between the lateral corner of the nail and the interphalangeal joint. Leah Rizack, a CNM and Dipl. Acupuncture, taught me that both points may be used. I have only used Spleen 1, and never found the need to use the other. If this simple technique does not work, continue with your normal midwifery protocol.


Ok ladies...don't laugh at my artistic attempt..but E. asked where to poke to stop a bleed.....have a look...X marks the spot...

                           look down at your  left toe


                                ______________





                           I    I             I      I


                           I    I   (nail)   I      I      outer edge of foot


                           I     I______I        I


                            I                   X  I


                              I                    I

Another Description of Acupressure Point

This is the fastest, most reliable non-drug way I know of to control a pph bleed. It uses an acupuncture technique, and you don't need to be concerned about the Spleen qi deficiency/blood stasis/blood heat differentiation (see post on herbs) to use it.

It involves a technique called bleeding, and it is just what it sounds like. You use a lancet to puncture an acupuncture point called Spleen 1. Its function is to control abnormal uterine bleeding. The method of puncture is slightly different than when getting a finger stuck, you are only after a small drop of blood or interstitial fluid. You don't need a great amount.

Choose either side, although if you're savvy enough with Chinese medicine you can start on the left side (left side rules the blood) for a hemorrhage that is profuse, bright red, or bright red and thick (sx of blood heat), or dark red and clotty (sx of blood stasis) and the right side (right side rules qi) for a pale, profuse watery bleed in an exhausted mother (qi deficiency). in any case, if you can't remember, just do it! It will still work.

The puncture is made in skin, just off the medial corner of the nail. Locate the point that is just proximal to the medial corner of the nailbed of the great toe. Imagine a line drawn down the medial edge of nailbed and a perpendicular one drawn across the proximal edge. Where these two intersect is the location of the point: [Just below corner of big toe nail closest to inside ankle bone.] It takes just a few seconds to do, and works within moments, if it is going to. It is well worth the time, and hardly adds any. If it doesn't work, take the next step in your protocols.


Homebirth and Postpartum Hemorrhage


Methergine is slower acting than pitocin but lasts much longer in the system - up to 2 hours.

A protocol we use based on the advice of our OB backup is to give one IM injection of Pitocin, if no response then repeat. If still no response or there is still concern give methergine IM. He felt that the receptors for pit would be exhausted after 2 IM injections so it was better to go to methergine next (of course considering the blood pressure was not high - which it usually isn't if we get to this part). We usually begin an IV after 1000 to 1500 cc loss and put an amp of pit in the bag. Women seem to feel better from the extra fluid and their milk comes in better.

I also use various herbs and/or homeopathics before the first pit. My favorite is erigeron/cinnamom compound from Herb Pharm out of Williams, Oregon.


How to Rub Up a Contraction

At the first sign of bleeding, I like to use a very gentle broad-handed, (wide spread fingers), even, balanced rubbing (touching?). I hesitate to call it massage because I don't mean "kneeding" the uterus. I'm trying to get a firm co-ordinated uterinc contraction, and don't want to stimulate part of the uterus more than another. My hands are pretty still at first, just giving even presure to remind the uterus to firm up. Once I get a firming up then I make the rub stronger if needed, sort of like "packing the uterus together" --like you do when you turn out dough... I think "holding" the uterus seems to work better than the frequently taught "kneeding" method. I wish I could demonstrate, I'm feeling inadequate with words.

I got the method out of old text and it really does seem to work well. (book is out on loan, otherwise I'd type the authors description). The theory is this broadhanded "holding" can be done before delivery of the placenta without increasing the risk of inco-ordinate contractions which could bring the danger of partial separation and more blood loss.

Knock on wood, thank the Lord, light a candle or whatever -- but I haven't used pit/herbs etc in years. VERY few moms bleed more than we like to see.



Blood Loss with Birth Chair



I have only recently had much experience with a birth stool, mostly with the DeBy and I am upset by how much more blood I feel I see immediately after the baby comes out when women are on the stool.

I don't know if it just the upright position and what I am seeing is the last of the amniotic fluid mixed with blood, but women just seem to GUSH right after the baby, until I get them on the bed, and then it slows right down. All that fluid loss makes me (a very new midwife, working out of hospital) very nervous.

However, I love the stool for women who can't/don't want to/are afraid to push, especially first-timers. It is amazing.

What do all you wise women (with many more births under your belt) find on the blood loss issue of stool vs. bed or other position?


I think you just see it easier - it comes out quicker, faster, and possibly mixed with amniotic fluid. Haven't ever noticed it really being more measured blood loss on a birth stool.


I also used to think that it was just that we were SEEING more blood on a birth stool, and it made sense that you wanted the blood OUT so the uterus could clamp down more efficiently.  However, after a chat with a very experienced midwife and re-thinking some of the births where I was seeing more bleeding OR retained placentas on the birth chair, I have formed the following theory.  I think that being on the birth chair somehow keeps the uterus from relaxing, and if it doesn't relax, it can't contract again to release the placenta, or to finish releasing it in the case of a partial separation.  My current practice is to have moms get on the birth stool if it's convenient, e.g. if she's getting out of a birth tub, and there's no bed nearby, BUT . . . if the placenta doesn't come in a reasonably amount of time, OR if I see flowing blood without a placenta coming right behind it, then I'll move her to a lying down position so the uterus can relax and the contract again to finish the job.



Herbs for Postpartum Hemorrhage



Thought I would jump in here as this is what I would use as well. My birth kit is still developing so I try to keep the bare necessities in it right now. Among the herbs I carry are Witch Hazel and Blue Cohosh. Whether placenta is still attached or not I would use 1 dropper each Witch Hazel and Blue Cohosh (or less if the mother is very sensitive). This Witchhazel is not the astringent but an herbal extract (or tincture).

After the birth of the placenta I would use a combination called Wombstringe (formerly known as PPH). Is has in it Shepherds Purse, Bayberry Bark, Motherwort, and Witch Hazel. This is made by Wishgarden Herbs.

If the mother is bleeding profusely I would skip the herbs and go on to the heavy hitters like bi manual and/or pit. I would use the herbs for a woman who is bleeding heavily and I am concerned. We have used pit at only one of the births I have attended and it didn't help (retained placenta). The herbs we rarely use but have had good results with. Hope this answers your question.


Yunnan Pai Yao, aka Yun Nan Bai Yao


Concerning an herbal patent called Yunnan Pai Yao, aka Yun Nan Bai Yao or other variations.

It is made entirely of one herb, whose pharmaceutical name is Radix Pseudoginseng, pinyin is San Qi, and Latin is Panax notoginseng or Panax pseudoginseng. It is similar in morphology to Panax ginseng- Chinese ginseng, but its properties are entirely different.

Whereas Chinese ginseng tonifies "qi", meaning it increases energy and organ function, Yun Nan Bai Yao stops bleeding. It also has an action of transforming blood stasis.

The causes of bleeding in Chinese medicine are many and varied. Abnormal heat, both vacuous and replete (meaning empty and excess) can cause it. In hemorrhage, this usually results in a heavy, profuse thick bright red flow. Blood stasis can also cause abnormal bleeding. This means that the blood actually blocks the normal channel of flow, and so the blood flows out of the vessels, much like a stream will overflow a log dam. Unless the stasis is resolved, the bleeding will continue. This type of bleeding is usually characterized by darker clotty flow and is accompanied by pain.

Two other types of bleeding are caused by a "qi" vacuity, meaning that the normal energy and organ function is weak. The first of these is a spleen qi vacuity. The spleen is responsible for "holding" the blood within the vessels, This type of hemorrhage is profuse, pale or watery, often the slow trickle type. The woman is typically exhausted and pale. The second type of qi vacuity hemorrhage is one where the qi is "sinking." This is also a malfunction of the spleen, which is supposed to ascend energy in the body and keep things from falling or "sinking." This type will be the same as the spleen qi vacuity hemorrhage, with the addition of prolapse, or a heavy downward falling feeling in the abdomen.

Yun Nan Bai Yao has the unique quality of stopping bleeding and resolving stasis at the same time. Because a stop bleeding herb acts on the emergency symptom, it works regardless of cause, so you don't have to spend much time or brain power figuring out the differentiation.

Yun Nan Bai Yao comes in three forms: a powder, encapsulated powder, and a hard to find alcohol extract. The powders come with a small red pill. The red pill is not Radix Notoginseng, so DON'T make the mistake of thinking that it's a stronger form of the herb. The red pill is made of herbs for loss of consciousness, which are very aromatic, somewhat like smelling salts, only in an oral form. This red pill will scatter the energy greatly, which is something you want if someone needs treatment for loss of consciousness, but not for hemorrhage itself. If the hemorrhage is from a qi vacuity and you give the red pill, you may exacerbate the condition that caused the hemorrhage by scattering already vacuous qi and actually precipitate shock. If you can't remember this, then remember to throw the red pill away. It's better not to use it than to use it incorrectly.

Because the capsules will take time to break down, it is advisable to use the powder for a postpartum bleed. The powder will form a suspension in water, it won't completely dissolve. Place about 1 teaspoon in 1/2 cup water, stir vigorously and have the woman chug the swill. (Those are medical terms :).) You can give up to 1/2 the small vial in this way, but if it doesn't work within just a few minutes, I'd go on to the next thing in my protocol, or combine the stop bleeding treatment with something more to the cause of the hemorrhage.

The capsules are useful for other, less emergency type bleeds such as prolonged postpartum bleeding, and to aid healing around surgery. The dose is 2 capsules 4 times a day. If you know someone is having surgery, have them take two capsules the last time they're allowed anything by mouth and the first thing after the surgery. They can then continue with the dosage above.

The Chinese Medicine approaches to hemorrhage are very specific, and Yun Nan Bai Yao (Yunnan Pai Yao) is one of those herbs that are easy and effective. Other techniques and herbs exist for hemorrhage. If you have an opportunity to attend any of the Midwifery today conferences, I've started doing a presentation on Chinese medicine for midwifery emergencies. If you want more info the two part class on Chinese Medicine is more in depth.

Yunnan Bai Yao, as a blood mover, is contraindicated for bleeding during pregnancy. These bleeds are sometimes caused by the same etiologies as postpartum bleed, but in pregnancy it is vital to be sure of the cause before giving something that might move the blood. So don't make a mistake--differentiate! (And please, don't guess!)

Zand herbals is introducing a new Chinese Classic line of herbal tinctures, with a new distillation process that make them very effective. They will be marketing a Hemostatic Formula that midwives could use for postpartum hemorrhage of any kind that I believe will be much more effective than Yun Nan Bai Yao. They typically sell only to people trained to use TCM formulas, so you may have to procure it through a friendly acupuncturist.


Thanks for some more info on Yannan Pai Yao (though I confess to a complete bafflement about Chinese medicine[Grin]. I will leave it to those of you who are expert in it).

Got a big question though. If you feel this is good medicine for bleeding, then what do you think of the rapidly growing practice of using it with no bleeding -- simply prophylactically at every birth? Do you feel this is indicated?


I think that the leap that if something is good when indicated, it must be just as good when not indicated is almost like using pitocin prophylactically. HERBS ARE DRUGS. They need to be used with full understanding of how they work, and should NEVER be applied in a manner in which they are not intended.

That said, Yunnan Bai Yao is one of the few herbs that can be used to stop bleeding with relatively few side effects. However, since it is also a blood quickener, and that means that energetically it moves the vital substance called blood, in a qi vacuity (meaning a lack of energy), given prophylactically, it could theoretically cause a bleed when there wasn't one. HOWEVER, Yunnan Bai Yao, being a styptic and blood mover, can be used whenever there is trauma, such as an episiotomy or tear, even in qi vacuity, AS LONGER AS THERE IS INDICATION FOR ITS USE. That indication can be surgery, trauma, bruising, and not necessarily a postpartum bleed.

Most likely those who might use it prophylactically won't see any kind of deleterious effects in the relatively small numbers a of private practice. This is because the doses given are still rather small. They are large enough to be effective when indicated, but small enough not to generate unwanted side effects, most of the time. It is also the gentle nature of the particular herb that contributes to it not producing side effects.

Your question presents the opportunity to caution midwives about the way they use herbs. Those who have a nursing background would never dream to be doling out drugs the way herbs are sometimes used. In my mind, herbs are drugs. Most of them have fewer side effects than pharmaceuticals because the active agents occur in combination with other substances that may mitigate side effects, or contribute to soften or counteract the effective action of the herb. Many herbs we use could be classified as a food, like Red Raspberry, and as such, have few, if any side effects. But when we start talking about herbs that have stronger actions, particularly the whole class of those that effect the blood, either to nourish it or to stop bleeding, it should be standard that you study and know the action of each, the dose, the route of administration, contraindications and side effects just like you would a drug. What I observe is that someone mentions that this herb is good for that, and before you know it, it is used for something else entirely. Intuition is good, but so is logic, and intuition that springs out of a knowledgeable and logical base is the most powerful of all.


Vaso-Vagal Response to Cervical Distention


I would love to know if anyone else on the list has had experiences like this, because there is little written in the texts on this topic, especially vaso-vagal response in relation to cervical distention after birth...

Yes, we've discussed it before. Saw a lot of vaso-vagal when I worked in radiology as a nurse. The difference is sudden drop in BP, without lots of blood loss, as opposed to hemorrhage, where you may see temporary rise in BP, or at least widening pulse pressures first as compensatory mechanisms, accompanied by rapid pulse, and usually rapid breathing. With v/v you usually see a low pulse, the vagal stim is also affecting heart rate to slow down. It may also be seen a few hours pp if there is a hematoma building. (saw this on occasion in pp ward. ) Sometimes the two can go together to some degree, which is confusing, but if you have hemorrhage, you will likely be massaging the uterus, and thus usually taking care of the vagal stim. Some women seem to get v/v reactions just from "normal" second stages though. One person I know has this with every baby. Anyone with suggestions for next time around?


My understanding, with hypovolemic shock, is that pulse pressures narrow, which goes along with the rapid, thready pulse, before BP drops. Which is why monitoring pulse is more useful than monitoring BP (since a BP drop is a late event in PPH).

Uncorrected, vasovagal syncope can progress to hypovolemic shock (because of hypoperfusion due to the bradycardia), so that secondarily, pulse will rise in response to the hypovolemia. Which is where the confusion can rise.

I guess my question is, however, how distention of the cervix after birth (by clots or by the placenta) can elicit a vasovagal response, since the uterus itself is not innervated by the vagus nerve, but the sacral outflow. Vasovagal syncope is usually talked about as being elicited by fear or threat or pain...which is why you'd tend to see it in radiology, or why it can be a problem with venipuncture. So I am looking for an answer as to why it would be elicited at this point.



Herbs for Third and Fourth Stage



Herbs:

Single tinctures: shepherd's purse - which I love and keep with me; blue cohosh, white oak bark; bethroot; bayberry.

Combination tinctures: Bayberry, White Oak bark & Cayenne; Motherwort, Shepherd's purse & bayberry; Blue Cohosh, Bayberry, yarrow, and Capsicum; Shepherd's purse, Blue Cohosh, Yarrow.

Homeopathics: (from Christian Midwifery, 2nd) Aconite, Apis, Arnica, Arsenicum album, Calcarea Carbonicum, Carbo Vegetabilis, China, Kalicarbonicum, Laurocerasus (I've heard wonder stories about the last one - Laurocerasus), Phosphorus.

Cayenne

Lots of folks here use cayenne as an antihemorrhagic -- T They give tincture or tea at the first sign of heavy bleeding, and seem convinced that it's effective. Do others use it?


I like to keep capsicum in my birth kit to use along with other tinctures to move them quickly into the bloodstream. It really flushes the system and opens it to all other remedies. Especially when I want them to act quickly. It doesn't take much so you must be careful.


If using capsicum in tincture form, try a vinegar based tincture. Though it still burns going down, it doesn't have the added alcohol bite to go along with it. I find it very pleasant tasting myself (but I like spicy things) and yet you still get the benefit of a quick route to the bloodstream. With capsules it just takes too long.


I'm wondering if cayenne contracts the blood vessels or the uterus, or both. If it contracts the uterus, how could it help migraines??? If it contracts the blood vessels, how could it also contract the uterus?? Does blood flow have anything to do with migraines?? This is too complicated, or too magical, for me.


It's not really too complicated, or too magical, or anything like that. Uterus is smooth muscle; blood vessel walls have smooth muscle. They contract and they can be stimulated to contract by either nerve stimulation or by chemical stimulation.

Not sure exactly how and why cayenne works to alter blood flow or to make the uterus contract, but changes in blood flow to the brain are thought to be one of the factors involved in migraine. Contraction or relaxation of the smooth muscle in the blood vessel walls alters their diameter - and there fore allows less or more blood to flow through the vessels. In the uterus, it could be either a direct effect of the cayenne (from the bloodstream) making the uterus contract or it could be something to do with changes in blood flow to the muscle. Bit of a puzzle really.



Concerns about Methergine




Methergine from drugs.com - can cause a rise in blood pressure, so it shouldn't be used with moms who already have high blood pressure;.



Use of Methylergonovine in Breastfeeding Mothers - Recently the FDA issued a warning about the accidental administration of Methergine injection to newborns,  and for some reason,  also warned against the use of this product in breastfeeding mothers,  suggesting a waiting period of 12 hours following its last use.  They did not explain if they have data suggesting reported toxicity in breastfed infants.



Cytotec / Misoprostol for Prevention/Treatment of Postpartum Hemorrhage



IMPORTANT - Postpartum use of Cytotec/misoprostol is very different from prenatal or intrapartum use, i.e. before the baby is born.  During labor, before the baby is born, Cytotec can cause contractions that are too strong for the baby . . . they can squeeze the placenta so tight for so long that there's not enough oxygen getting through to the baby; this can cause severe fetal distress.  Or, if the baby is not fitting into the pelvis (obstructed labor), the very strong contractions caused by Cytotec can actually cause a tear in the birthing woman's uterine muscle, which is called a uterine rupture; this could also be catastrophic for the baby.

After the baby is born, contractions caused by Cytotec given to the mother no longer affect the baby.  After the baby is born, the risk of uterine rupture also goes away because once the baby is outside the mother's body, there is no possibility of an obstructed labor.  So Cytotec is also safe for controlling postpartum hemorrhage in VBACs.



Studies are showing that 400 mcg is effective and reduces side effects.  It makes sense to start with 400 mcg and only use another 200-400 mcg as needed.  Note that misoprostol is for EMERGENCY USE when other oxytocics are ineffective or contraindicated.  It is particularly helpful for a bleed in a mom who has a low-lying placenta and high blood pressure--pitocin isn't as effective in the lower uterine segment, and methergine can elevate blood pressure.


RECOMMENDATION: STOP USING PROPHYLACTIC RECTAL CYTOTEC [1/6/12]:

To PREVENT PPH?  IV Pitocin was more effective than rectal Cytotec in controlled trials and resulted in less maternal side effects.

To TREAT PPH?  Cytotec can be an effective uterotonic agent after failure of oxytocin & methergine.  It is comparable to hemabate.

SUBLINGUAL BETTER  For treating PPH with Cytotec, sublingual route gives faster absorption & improved response compared to rectal route.

DOSAGE of CYTOTEC  For PPH treatment, 400 mcg is as effective as 600 or more with fewer side effects.  For PPH prevention, use Pitocin.


Which route of administration is best?

The pharmacokinetics and different regimens of misoprostol in early first-trimester medical abortion.
Tang OS, Ho PC.
Contraception. 2006 Jul;74(1):26-30. Epub 2006 Apr 27.

"
A pharmacokinetic study has shown that sublingual misoprostol has the shortest onset of action, the highest peak concentration and the greatest bioavailability among the three routes of administration."


Pharmacokinetics of different routes of administration of misoprostol.
Tang OS, Schweer H, Seyberth HW, Lee SW, Ho PC.
Hum Reprod. 2002 Feb;17(2):332-6.

RESULTS: Sublingual misoprostol achieved the highest serum peak concentration (Cmax) (574.8 +/- 250.7 pg/ml) of MPA and this was significantly higher than those in the other groups [Oral: 287.6 +/- 144.3 pg/ml (P < 0.01), vaginal: 125.2 +/- 53.8 pg/ml (P < 0.001) and vaginal with water: 162.8 +/- 57.1 pg/ml (P < 0.001)]. The time to peak concentration (Tmax) was similar in both the sublingual (26.0 +/- 11.5 min) and oral groups (27.5 +/- 14.8 min) and was significantly shorter than those in both vaginal groups. The area under the MPA concentration versus time curve up to 360 min in the sublingual group (743.7 +/- 291.2 pg.h/ml) was significantly greater than those in oral (402.8 +/- 151.6 pg.h/ml, P < 0.05) and vaginal (433.7 +/- 182.6 pg.h/ml, P < 0.05) groups, but no significant difference was found between sublingual and vaginal administration if water (649.3 +/- 333.8 pg.h/ml) was added.


Administration of misoprostol by trained traditional birth attendants to prevent postpartum haemorrhage in homebirths in Pakistan: a randomised placebo-controlled trial. [Full text]
Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, Walraven G, Hatcher J.
BJOG. 2011 Feb;118(3):353-61. doi: 10.1111/j.1471-0528.2010.02807.x. Epub 2010 Dec 23.

RESULTS: oral misoprostol was associated with a significant reduction in the rate of PPH (≥ 500 ml) (16.5 versus 21.9%; relative risk 0.76, 95% CI 0.59-0.97). There were no measurable differences between study groups for drop in haemoglobin >2 g/dl (relative risk 0.79, 95% CI 0.62-1.02); but significantly fewer women receiving misoprostol had a drop in haemoglobin >3 g/dl, compared with placebo (5.1 versus 9.6%; relative risk 0.53, 95% CI 0.34-0.83). Shivering and chills were significantly more common with misoprostol. There were no maternal deaths among participants.

CONCLUSIONS: postpartum administration of 600 microg oral misoprostol by trained TBAs at home deliveries reduces the rate of PPH by 24%. Given its ease of use and low cost, misoprostol could reduce the burden of PPH in community settings where universal oxytocin prophylaxis is not feasible. Continual training and skill-building for TBAs, along with monitoring and evaluation of programme effectiveness, should accompany any widespread introduction of this drug.


I'd really like to see a statistical analysis of the relative effectiveness of pitocin and misoprostol in women who have given birth naturally, without any exogenous pitocin.  You would expect these results to be even more favorable than in women who have had c-sections or exogenous pitocin in order to give birth.  When you give birth with only endogenous oxytocin, you know that the uterus is very receptive to oxytocin/pitocin and thus would expect the uterus also to respond very well to other oxytocics.  Exceptions might be if the mom is a grand multip and the uterus didn't have to work very hard to give birth, or if the labor was prolonged and the uterine muscle is just exhausted.  In that case, hydrating with an electrolyte-enhanced calorie-rich fruit drink should help a lot.


Misoprostol use in the community to reduce maternal death.
Gülmezoglu AM, Mathai M, Souza JP, d'Arcangues C, Mbizvo M.
Lancet. 2010 Sep 18;376(9745):955; author reply 955-6.


The full text of this article is available for free.

Misoprostol to prevent and treat postpartum haemorrhage: a systematic review and meta-analysis of maternal deaths and dose-related effects.
Hofmeyr GJ, Gülmezoglu AM, Novikova N, Linder V, Ferreira S, Piaggio G.
Bull World Health Organ. 2009 Sep;87(9):666-77.

Abstract

OBJECTIVE:

To review maternal deaths and the dose-related effects of misoprostol on blood loss and pyrexia in randomized trials of misoprostol use for the prevention or treatment of postpartum haemorrhage.

METHODS:

We searched the Cochrane Controlled Trials Register and Pubmed, without language restrictions, for '(misoprostol AND postpartum) OR (misoprostol AND haemorrhage) OR (misoprostol AND hemorrhage)', and we evaluated reports identified through the Cochrane Pregnancy and Childbirth Group search strategy. Randomized trials comparing misoprostol with either placebo or another uterotonic to prevent or treat postpartum haemorrhage were checked for eligibility. Data were extracted, tabulated and analysed with Reviewer Manager (RevMan) 4.3 software.

FINDINGS:

We included 46 trials with more than 40,000 participants in the final analysis. Of 11 deaths reported in 5 trials, 8 occurred in women receiving >or= 600 microg of misoprostol (Peto odds ratio, OR: 2.49; 95% confidence interval, CI: 0.76-8.13). Severe morbidity, defined as the need for major surgery, admission to intensive care, organ failure or body temperature >or= 40 degrees C, was relatively infrequent. In prevention trials, severe morbidity was experienced by 16 of 10,281 women on misoprostol and by 16 of 10,292 women on conventional uterotonics; in treatment trials, it was experienced by 1 of 32 women on misoprostol and by 1 of 32 women on conventional uterotonics. Misoprostol recipients experienced more adverse events than placebo recipients: 8 of 2070 versus 5 of 2032, respectively, in prevention trials, and 5 of 196 versus 2 of 202, respectively, in treatment trials. Meta-analysis of direct and adjusted indirect comparisons of the results of randomized trials showed no evidence that 600 microg are more effective than 400 microg for preventing blood loss > 1000 ml (relative risk, RR: 1.02; 95% CI: 0.71-1.48). Pyrexia was more than twice as common among women who received > 600 microg rather than 400 microg of misoprostol (RR: 2.53; 95% CI: 1.78-3.60).

CONCLUSION:

Further research is needed to more accurately assess the potential beneficial and harmful effects of misoprostol and to determine the smallest dose that is effective and safe. In this review, 400 microg of misoprostol were found to be safer than > 600 microg and just as effective.


Misoprostol reduces severe postpartum hemorrhage [Full text]

BMJ. 2005 Oct 1;331(7519):723.
Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial.
Hoj L, Cardoso P, Nielsen BB, Hvidman L, Nielsen J, Aaby P.

CONCLUSION: Sublingual misoprostol reduces the frequency of severe postpartum haemorrhage.


A Lesser Known Role for Misoprostol (search within Seven Ways to Control Postpartum Hemorrhage by Ashley S. Roman, MD, MPH, Andrei Rebarber, MD)


From the Cochrane Collection [from year 2000]

"Although the effectiveness of prostaglandins and their analogs for arresting postpartum hemorrhage due to uterine atony has not been demonstrated in controlled trials, their dramatic effect when all other measures have failed shows that these drugs are worthwhile."


From "Know Your Options for Peripartum Hemorrhage" by Kerri Wachter in Ob. Gyn. News, October 1, 2005: "Based on the literature, the evidence is not sufficient at this time to support routine use of misoprostol for the prevention of PPH.  'The drug has such a high safety profile that it may be more useful in a treatment role" said Dr. Mayer.  He recommends using 800-1,000 mcg administered rectally.'"



Tip for Rectal Administration of Cytotec: Carry the misoprostol tablets in a new Monistat plunger.  When you need to use it, just put a little lubricant on the tip of the plunger and insert it just inside the rectum and push the plunger.

Buccal misoprostol to decrease blood loss after vaginal delivery: a randomized trial.
Bhullar A, Carlan SJ, Hamm J, Lamberty N, White L, Richichi K.
Obstet Gynecol. 2004 Dec;104(6):1282-8.

RESULTS: A total of 848 patients were enrolled and 756 randomly assigned, 377 in the misoprostol group and 379 in the placebo group. Demographic, antepartum, and intrapartum characteristics were similar between the groups. The incidence of postpartum hemorrhage, 3% compared with 5%, (relative risk 0.65, 95% confidence interval 0.33-1.29, P = .22), mean estimated blood loss, 322 compared with 329 mL, (P = .45), and mean minutes of the third stage of labor, 6.7 compared with 6.9 (P = .52) were similar between the groups, misoprostol and placebo, respectively. Hemoglobin difference before and after delivery, need for second or third uterotonic agent, and all measured neonatal variables including birth weights, and umbilical cord pH were similar between the groups. CONCLUSION: Buccal misoprostol at cord clamping is no more effective than placebo in reducing postpartum hemorrhage.

Ed: Some critical thinking - The use of Cytotec reduced the incidence of postpartum hemorrhage by half;  I don't know why this is considered statistically insignificant.  It looks to me like Cytotec is reducing the bleeding.  Also, this study used 200 mcg Cytotec orally, whereas most postpartum hemorrhage protocols call for up to 600 mcg rectally for fastest absorption.  And this study is about prevention, not treatment of PPH.


Prevention and Treatment of Postpartum Hemorrhage: New Advances for Low-Resource Settings
Suellen Miller, CNM, PhD; Felicia Lester, MPH, MS; Paul Hensleigh, MD, PhD
from Journal of Midwifery & Women's Health
Posted 07/27/2004 on Medscape - registration is free


OK, now here's the study I'm looking for . . . is Cytotec effective at treating postpartum hemorrhage?  This study says Yes!

Controlling postpartum hemorrhage after home births in Tanzania.
Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F.
Int J Gynaecol Obstet. 2005 Jul;90(1):51-5.

Objectives: Determine safety of household management of postpartum hemorrhage (PPH) with 1000 mug of rectal misoprostol, and assess possible reduction in referrals and the need for additional interventions. Methods: Traditional birth attendants (TBAs) in Kigoma, Tanzania were trained to recognize PPH (500 ml of blood loss). Blood loss measurement was standardized by using a local garment, the "kanga". TBAs in the intervention area gave 1000 mug of misoprostol rectally when PPH occurred. Those in the non-intervention area referred the women to the nearest facility. Results: 454 women in the intervention and 395 in the non-intervention areas were eligible. 111 in the intervention area and 73 in the non-intervention had PPH. Fewer than 2% of the PPH women in the intervention area were referred, compared with 19% in the non-intervention. Conclusion: Misoprostol is a low cost, easy to use technology that can control PPH even without a medically trained attendant.


A recent study from South Africa compared a combination of intramuscular syntometrine injection and oxytocin infusion to rectal misoprostol and found that those who received misoprostol had a statistically significant reduction in bleeding and further medical cointerventions to control the bleeding (6% versus 34%) (RR, 0.18; 95% CI, 0.04-0.67).[48] Sharma and El-Refaey[49] reviewed the South African study and other descriptive, observational, and randomized studies of 800 and 1000 mcg of rectal misoprostol in the treatment of postpartum hemorrhage. They concluded that the use of rectal misoprostol is a relatively easy, non-invasive, and potent treatment for postpartum hemorrhage and recommended that it be added to oxytocin and ergometrine as a first-line agent in the "therapeutic drill" in the steps taken to treat postpartum hemorrhage.


I carry Cytotec tablets in my kit strictly in case of PPH and pray that I never have to use it. My backup doc insisted that  I do so, citing his own experience with using it rectally for a PP hemorrhage when Pit/Meth/Hemabate failed and the result was impressive.  He has delivered babies for almost 40 years, and I respect his opinion, and carry it.


Is rectal misoprostol really effective in the treatment of third stage of labor? A randomized controlled trial. [Expanded abstract]
Caliskan E, Meydanli MM, Dilbaz B, Aykan B, Sonmezer M, Haberal A.
Am J Obstet Gynecol 2002 Oct;187(4):1038-45

CONCLUSION: Rectal misoprostol is significantly less effective than oxytocin plus methylergometrine for the prevention of postpartum hemorrhage.


Well, it looks as if different studies show different results regarding the relative efficacy of pitocin and Cytotec.  It almost makes you wonder if the different drug companies are jockeying for the market.


I think the mistake is trying to find the one drug that works best in all circumstances.  My personal experience has been that Cytotec is superior to pitocin for dealing with any kind of partial separation - it gets that placenta out quickly and easily, and then you can focus on any atony issues.  I also find Cytotec to be superior for those low-lying placentas; it does the work of methergine without creating worries about blood pressure.  PPH problems may be multi-factorial, and in a true emergency, it makes sense to use all the tools at hand instead of limiting yourself to just one.


Oxytocin Superior To Misoprostol In Third Stage Labour Lancet [08/30/2001, Lancet 2001; 358: 689-95]

"Oxytocin has been found superior to the hormone derivative misoprostol in reducing maternal blood loss immediately after childbirth.

A double blind randomised controlled trial in Argentina, China, Egypt, Ireland, Nigeria, South Africa, Switzerland, Thailand, and Vietnam found that "10 IU oxytocin (intravenous or intramuscular) is preferable to 600 g oral misoprostol in the active management of the third stage of labour in hospital settings where active management is the norm."

The trial was directed by Dr José Villar and colleagues at the UNDP/UNFA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Production, Department of Reproductive Health and Research, Geneva, Switzerland.


Misoprostol May Be Preferable to Other Postpartum Oxytocics in Some Settings  [Medscape registration is free]


Lots of related Medline articles


The use of rectal misoprostol as active pharmacological management of the third stage of labor.
Diab KM, Ramy AR, Yehia MA
J Obstet Gynaecol Res 1999 Oct;25(5):327-32


Randomized comparison of rectal misoprostol with Syntometrine for management of third stage of labor.
Bamigboye AA, Merrell DA, Hofmeyr GJ, Mitchell R
Acta Obstet Gynecol Scand 1998 Feb;77(2):178-81


Ulcer Drug Could Save Mothers, UK Researcher Says

March 4, 1997

12.23 p.m. (1723 GMT)
LONDON -- A drug originally designed to treat ulcers could help stop bleeding after delivery and has the potential to save 250,000 lives a year, a British researcher said on Tuesday.

The drug, misoprostol, was designed to counteract stomach damage caused by painkillers. It is also used to induce abortion. Dr. Hazim el Refaey, an obstetrician at University College Hospital London, tested misoprostol pills on 250 women.

They worked just as well in preventing haemorrhage after delivery as did the standard treatment, an injection of the drug syntometrine, he reported in the British Journal of Obstetrics and Gynecology.

Syntometrine, given routinely after birth in Europe and North America, can cause nausea and raise blood pressure. But misoprostol has no side-effects and does not have to be injected, Refaey said.

In addition, misoprostol is more stable than syntometrine and can be used more widely in countries with hot climates. The World Health Organisation (WHO) estimates that in countries that lack such a drug, 250,000 women die every year from haemorrhage after birth.

"In this pill we seem to have an easy-to-administer, easy-to-store and safe-to-take precaution against hemorrhage following childbirth," Refaey said in a statement.

"It could save the lives of hundreds of thousands of women around the world every year."

He said WHO was setting up a global trial of misoprostol.


In reference to the question about use of misoprostol in prevention of postpartum hemorrhage. I personally do not have any experience with this, however you may want to look at "Use of Oral misoprostol in the Prevention of Postpartum Haemorrhage" in the March issue of British Journal of Obstetrics and Gynaecology . This was a prospective study of 237 woman given 600 ug of misoprostol orally after delivery and demonstrated the rate of postpartum hemorrhage to be the same as that seen with oxytocin and methergine. Perhaps a double blind, randomized trial will be conducted to truly give us an answer.


1. i have the distinct impression that postpartum bleeding is less after misoprostol. hard to prove. anyone else have same impression? might be valuable to study.

2. while waiting the other night, as usual, for the placenta to deliver after a preterm birth (seems like they take forever), i had the bright idea to give her an oral dose of misoprostol. great effect, little bleeding. have others done this (?routinely instead of pit?)?


cytotec can be used to stop pph also (400 to 800 mcg rectally for acute or 200 mcg q 4 hours x 6 in lieu of methergine)


Midwives' Experience with Cytotec for Postpartum Hemorrhage:


Yes, I have experience with cytotec rectally for PPH.  You can use 200-800 micrograms into the rectum - it works very well.


I would prefer to be able to give PO but they are such hard little pills that i just can't see it dissolving fast enough even rectally to be of use .Perhaps for secondary PPH-


I ma reckoning then that where one cannot use pit (no fridge) the best way for active pph may be to dissolve 4 tabs of 200mcg into some juice (acid) and swallow -trying to speed up the absorption time rather than wait - prefer orally.

How much faster is it rectally than orally  and has anyone any thought on having the medication dissolved before PO by using some acidic swallow medium?


Rectally is faster than orally and does not have to go through the digestive system... There is slightly acidic fluid in the rectum, and the moisture is enough to dissolve.


We use 800.... Just put 4 pills in rectally all at once... onset of action seems to be within 5-10 min,.... easy, accessible... the pills are hard, but not enteric coated and will dissolve easily...  I think this is a good tool out in the field, with little or no IV access.


Side Effects of Misoprostol for the Mother and Baby

Here's the PDR-style information about Cytotec.  Note that there are lots of warnings about use DURING pregnancy, but the dangers of causing fetal distress or uterine rupture disappear once the baby is born.  The bottom of page 9 has information about overdosage and says that cumulate daily doses of 1600 mcg have been tolerated. The amount of Cytotec that is recommended for treatment of postpartum hemorrhage is 600-1000 mcg, well under the high daily dosage level.

The most common side effects for a postpartum mother seem to be the possibility of diarrhea in the hours shortly after birth, which actually helps to prevent postpartum constipation, so I don't even consider that a bad thing.  And they sometimes run a low-grade fever (around 100 or 101), although they feel completely well; this just requires additional "observation".

Read the FDA label

http:

"Nursing mothers: It is unlikely that Cytotec is excreted in human milk since it is rapidly metabolized throughout the body. However, it is not known if the active metabolite (misoprostol acid) is excreted in human milk. Therefore, Cytotec should not be administered to nursing mothers because the potential excretion of misoprostol acid could cause significant diarrhea in nursing infants."  [NOTE - This is never cited as a risk of misoprostol for postpartum hemorrhage.  I don't know whether this is because the benefits so massively outweigh the risks or whether it's not an issue because of the meconium.  And, again, diarrhea in a newborn would be JUST FINE, as it moves the meconium out faster, thus supplementing the laxative effect of the colostrum.  It wouldn't last long enough to cause the colostrum or breastmilk to leave the baby's body any faster.]

Misoprostol is very effective at controlling severe postpartum hemorrhage, even with a retained placenta.  It can control bleeding while a postpartum mother is transported for even the scariest placental issues, such as placenta accreta.  If you can get a mom to the hospital without losing more than a couple of liters of blood, she's much less likely to require a transfusion or suffer from Sheehan's syndrome.  It may save her life!


The evidence shows no significant risks to using misoprostol (brand name Cytotec) after the birth.  The potential side effects (diarrhea, elevated temperature) of postpartum use are almost insignificant.  Most women take stool softeners after birth anyway and would welcome looser bowels, and the elevated temperature is not accompanied by feeling unwell in any way.  (The baby might even enjoy the slight increase in the temperature of the mom's skin.)

I understand that the FDA needs to make sure that consumers know that misoprostol is not approved by the FDA for postpartum use.  From the manufacturer's point of view, it doesn't make any sense to spend money for the very expensive FDA approval process when this usage represents less than 1% of the drug's clinical use.

But there is no possibility of uterine rupture once the baby is out, and there is no possibility of fetal distress after the birth.  And there are numerous studies showing the efficacy of misoprostol for controlling postpartum hemorrhage.

So although it is not FDA approved for controlling postpartum hemorrhage, I have never heard of any side effects other than those listed above.

I speak out about this so frequently because I have clients who are very confused about why I would want to have anything to do with a pharmaceutical that has a reputation for having killed women when used BEFORE THE BIRTH.

Women have a right to know the whole truth about misoprostol, including its amazing ability to control PP hemorrhage, especially in women who have given birth naturally and thus have a demonstrated responsiveness to oxytocics.

The reason I am such a fan of misoprostol is because it works so beautifully.  In the ten years since I started carrying misoprostol for emergency control of postpartum hemorrhage, I have not needed to take a client to the hospital for any postpartum bleeding or retained placenta issues.

I think we serve women best by being crystal clear about the distinction between intrapartum and postpartum use of misoprostol.



Foley Catheters and Other Forms of Tamponade Balloons



The Re-Emergence of Uterine Packing with Balloon Devices (search within Seven Ways to Control Postpartum Hemorrhage by Ashley S. Roman, MD, MPH, Andrei Rebarber, MD)


OB Hemorrhage - Uterine Balloons Resources from CMQCC - California Maternal Quality Care Collaborative


Management of Postpartum Hemorrhage with the SOS Bakri Tamponade Balloon

More information about the Bakri Balloon


If you don't happen to have a Bakri Balloon handy, you can try Use of a Condom to Control Massive Postpartum Hemorrhage


Postpartum Hemorrhage:Third Stage Emergency -- ALSO.
This recommends misoprostol but not Foley, because the capacity of the Foley just isn't enough to pack the uterus firmly. The new Bakri Balloon solves this problem.



Midwife Discussion about the Use of the Bakri Balloon for homebirth



If a mom's bleeding that heavily, then she needs to be transferred to the closest hospital immediately because this is a life threatening emergency, out of the scope of practice of a home birth midwife-the balloon should never be used in the home:

www.obgmanagement.com
 
womenshealth.jhmi.edu/residency_mfm_programs/residents_current/sos_bakri/sos_bakri_balloon.pdf
 
ki.au.dk/fileadmin/www.ki.au.dk/forskning/forskningsenheder/gyn__kologisk-obstetrisk_afd__y/undervisning/obstetricia/tidligere_obstetricia/060914bakri.pdf 




I like to be able to offer my clients the best care possible, and if a Bakri Balloon will staunch the bleeding on the way to the hospital, how can that be a bad thing? I have seen EMS be incredibly slow about transporting moms who are hemorrhaging because she hasn't crashed yet and they can't see the bleeding if we've got pads on her and are protecting her modesty.  Besides, they have no sense of what is normal and what is excessive postpartum bleeding, and sadly, they do not always listen to the midwife.  The mom in question later required a transfusion because EMS took about 25 minutes to move her the 1.5 miles to our nearest hospital.  This was ten years ago now, and that is part of the reason why I've started carrying misoprostol to control postpartum hemorrhage while we're on the way to the hospital.  But misoprostol doesn't always work, and a Bakri Balloon would be a very useful addition to my emergency kit. Also, as the "Medical Coordinator" for our local Community Emergency Response Team, I'm stashing supplies so I can run a small birth center in my home after the next Big One, when our esteemed hospital staff will presumably have better things to do than attend normal birth, and we certainly will not have access to EMS for individual emergencies. And I know that there are a number of midwives in rural or remote areas who are many minutes away from a hospital, even in the best of times.

I don't have enough information on the Bakri yet to really comment on its safety for homebirth, but I will say that almost any available tools we can have to either stop or control hemorrhages either at home or en route to the hospital are important to look further into.  Transfers do take time, and EMS aren't always as fast about getting the mom to the hospital s they could be. When I have the chance, I prefer to self-transfer, and with significant bleeds, that is often not possible, because we need big, burly men for their ability to carry mom out--not so much because of any tools they have to assist the actual problem.  But EMS takes SUCH A LONG TIME, and they are fairly inexperienced in handling our obstetrical complications so that while time is being wasted, if the problem isn't controlled, then it's continuing.  So the idea of "transferring a badly-hemorrhaging mom to the hospital IMMEDIATELY" is nice in theory but impractical in reality.  Actual homebirth midwives who have been practicing for several years with at least a few hundred births under their belts should be consulted when the "powers that be" are determining what is actually within our scope of practice or not, because theory and practice rarely coincide perfectly. I remember working 1.5 years in Texas when pitocin, oxygen, lidocaine and suturing equipment were illegal for midwives to carry and use.


I looked at a few websites which herald the bakri balloon as the postpartum hemorrhage savior, but I'm trying to figure out why. How does it work to stop a hemorrhage? I always sort of thought that things inside the uterus prevent it from contracting and clamping off the uterine bleeders. I see that the bakri balloon has incredible success in stopping hemorrhages, but could someone excuse my ignorance and explain to me why it works?

The Bakri Balloon is the modern form of "packing the uterus", but it's much quicker and more effective. For midwives who attend homebirth, we're not likely to have progressed as far as a postpartum hemorrhage without a uterus that is adequately responsive to natural levels of oxytocin enough to contract, open the cervix and push out the baby.  So it's unlikely that the uterus would then not respond to oxytocin postpartum. Personally, I have never met a hemorrhage that wouldn't respond to either pitocin or misoprostol. (I've met a few that didn't respond very well to pitocin, but misoprostol has always [knock on wood!] done it for me.) And for midwives who don't already carry misoprostol as an emergency backup measure to control postpartum hemorrhage, it's much easier to get than a Bakri Balloon! But consider the OB who works with births where the mom isn't yet at term, so the uterus isn't as responsive to oxytocin.  Or anytime they do a pre-labor c-section, the uterus hasn't gone through the normal dance of reconfiguring the muscle fibers.  I don't know how much of this is responsible for the fact that the "normal" blood loss from a c-section is twice that for a vaginal birth.  But apparently women do still die on the operating table from postpartum hemorrhage from the uterus after a c-section. The Bakri Balloon puts compression on the placental "wound" from inside.  Apparently this can be a big difference in removing the urgency of doing an immediate hysterectomy to stop the bleeding.  That's a godsend for a lot of women. And it will save some lives, even in developed countries. It looks like it's mostly used for low-lying placentas where the placental wound is in the lower uterine segment, which is even less responsive to oxytocics. This is my understanding, which may not be perfect. It's very unlikely that a Bakri balloon would be a lifesaver at a homebirth where pitocin and misoprostol are used appropriately, along with other normal measures. However, I carry a lot of equipment that I'm likely never to use.  (Oral airways, for example.)  So I would still like to get a couple for my kit and supplies for my emergency post-earthquake birth center.
For midwives who attend births for truly grand multips, the Bakri Balloon would be great to have in their kit. For these women, there's just not that much muscle fiber left in the uterus, so it doesn't take that much work to open the cervix, but there's not much muscle fiber left to control the postpartum bleeding.  And oxytocics might not be enough to get adequate uterine contraction to control bleeding.  Or for a mom who is really exhausted and isn't metabolically competent to contract the uterus.


When using the bakri balloon, I geuss you insert it, inflate it and then... massage the uterus? I'm assuming there would be no "gentle cord traction" type activity because wouldn't that risk a uterine inversion? So you insert it, massage the uterus with the bakri inside, then when the bleeding slows/stops (after a few minutes?) you deflate and remove the balloon?



Since homebirth midwives would be using this as an emergency measure, I think you would insert it and inflate it, and this should stop the bleeding.  Meanwhile, you're transporting her to the hospital, where they can follow their protocols about removing it.


What about Methergine? I've never had anything that pitocin and methergine couldn't handle (>200 births). Do you find Cytotec to be effective in cases you've had that methergine is not effective? How fast does cytotec take effect when inserted rectally? I think I know the answer to this one: if you were to ever in worse case scenario, use the bakri balloon, would you still use it if you had given methergine and/or cytotec?


In my experience, misoprostol inserted rectally works very quickly, usually within a minute.  It's fantastic! If I can ever purchase a Bakri Balloon, I would be using it after it's clear that all the usual midwifery techniques aren't working, including uterine massage and compression, pitocin and misoprostol, and EMS is on the way. (I appreciate the wisdom of some of our senior midwives who consider the cervix to be a one-way valve except in extreme circumstances.  Putting something inside the uterus in an emergency is less likely to be completely sterile, and I'd want to be transporting her to the hospital for infection watch, if nothing else.  Call me cautious.) Anyway, I would only be using the Bakri Balloon to stop the bleeding while we're going to the hospital, where they can follow their protocols for removing it.

I certainly am not talking about routine use of Bakri Balloons; I'm just in favor of our access to purchasing them if we want to carry them and use them as a device of last resort.  Sometimes it's really nice to have a last resort that is actually effective!



We had a training workshop for use of this method during our Women Helping Women retreat in WV last year. The next repeat of the session will be on the Friday of the MANA conference in Nashville (I think that's 10/15/10). It is adapted to an OOH audience. A few of us have added this tool to our birthkits.



I also suggest midwives go to this site from Johns Hopkins on the use of the Bakri balloon, contraindications and protocols for use in the hospital before we jump on this band wagon.

SOS BAKRI TAMPONADE BALLOON CATHETER [Document no longer available]
Powerpoint Presentation: SOS BAKRI TAMPONADE BALLOON CATHETER . The Simple Solution for Postpartum Hemorrhage . Illustration by Lisa Clark



Assessing Blood Loss



Orthostatic BP's are a way of evaluating volume depletion. You take the mom's BP lying, sitting, then standing. If her BP goes down and pulse goes up she's considered to have orthostatic changes and may need fluid replacement.


If you have a woman with suspected hypovolemia from bleeding........weak, dizzy , BP lower than you like, but still there..... try to get some salty broth in her......a bouillon cube in hot water works well. This will pull volume from the interstitial and intracellular spaces into her intravascular and help keep her from passing out. It really works faster than you would think. We were always using this for the dialysis patients that we got "too dry".


An old time fix was known as shock remedy - - - A half teaspoon of salt in a pint of water (just put a good pinch of salt in a glass of water).

Another good thing is to add a pinch of salt to a glass of juice. (similar to rehydration drinks).



Detecting Clot Formation



I've only seen a huge clot once.  This was after a fairly normal placental separation and placental delivery about 15 minutes after the birth.  The mom had a history of PPH, and I had actually given her 800 mcg of Cytotec orally immediately after the birth of the baby, without waiting for any more serious signs of trouble.  Then, a few minutes after the delivery of the placenta, I noticed a sort of trickle bleed, but the blood was pinker, paler, more serous.  This tipped me off that the clotting factors were staying inside as a clot, and just the serous blood was flowing out.  I immediately did the most serious uterine compression I've ever done (while guarding the uterus - pro forma) and expressed a 350 cc clot.  I gave her another 800 mcg of Cytotec orally, and the bleeding eventually tapered off, without any additional clots larger than a quarter.  I did give her another 200 mcg of Cytotec after the baby had stopped nursing, about 2 hours after the birth.  And I left a packet of Cytotec with her, just in case.  She didn't have any additional hemorrhaging and very few afterpains.  I was very impressed with how contracted her uterus was at the 32-hour assessment; it was contracted to 3 fingerbreadths below the umbilicus.  We were all very grateful for Cytotec.



Surgical Remedies for Postpartum Hemorrhage



This is outside the scope of midwifery practice, but it's important for everyone to know!

Uterine Artery Embolization for Hemorrhage May Leave Fertility Intact [5/27/10]  - Uterine artery embolization for postpartum hemorrhage appears to have no significant effect on fertility, French researchers report in an April 8th online paper in Fertility and Sterility.



Guarding the Fundus



How many of us really feel that an abdominal hand "guarding the uterus" does even one tiny slightest bit of good to protect against prolapse or inversion? Does it strike anyone as a meaningless ritual? We are all taught to do it.. but I think it makes no logical sense.... Someone step out on this limb with me here[Grin]


Here I go, out on the limb again. I always do it. Don't know if it is meaningless or not, but it surely is harmless, causes no discomfort to the woman if done properly. I feel that it gives me a certain assurity that the uterus is staying UP where it belongs...and not trying to come out with the placenta.


This is exactly why I do it, too. I don't guard the fundus, I support suprapubically and can feel if the uterus moves downward against my hand with gentle cord traction. If it does, I wait a while longer. I don't think I'm preventing the uterus from prolapsing with the guarding hand.

On the contrary, I'm guarding myself against prolapsing the uterus. I've never had a prolapse or inversion in about 1400 births and plan to keep it that way!


I received some highly raised eyebrows at my last two births when I did NOT do "fundal guarding" - When my assistant/partner asked if I wanted HER to do it and I said "no" she couldn't help herself and quickly reached over and did it! Just couldn't bear to see that maternal abdomen without a midwives hand on it[Grin] - - I haven't "done" fundal guarding in many years, but this was the first time she noticed!


I don't have the book in front of me now, but it seems to me that Varney's Nurse-Midwifery (or maybe Myles?) stated that her reasoning for guarding the fundus during third stage was that if you've got your hand right there the whole time, you can easily make sure that nobody (hospital personnel) starts massaging the uterus--thus perhaps causing incoordinate contractions, partial separation and hemorrhage.


I can't remember reading this before, but I love it!

I almost never do fundal massage on my client's. If the bleeding is a bit much I will check to see if the uterus feels boggy, but unless there is a PPH happening I don't do any massaging. It seems to me that the women who do the most bleeding are those with large amounts of clots in the uterus, and I find that doing fundal massage while sweeping the clots out of the uterus with my other hand firms up even the most relaxed uterus and stops the vast majority of PPH's in their tracks. The rest of my clients have the luxury of not having their very sensitive uterus touched by anyone!



Postpartum Fundal Massage



One practice is related to massaging the uterus in the immediate postpartum period. After the placenta is delivered, some midwives massage the fundus prophylactically. They do this to 'expel any potential clots, which would not allow the uterus to clamp down properly'. I was originally taught to not massage the uterus unless indicated (i.e.: boggy uterus). That too much "fundus fiddling" can cause the uterus to stop clamping and therefore cause bleeding. Massaging the uterus hard enough to expel clots seems to be very painful for women. My experience is that clots are always expelled on their own in time. And I saw some pretty big ones!


Ooohhh, this is an interesting thread. I read a while back on the OB/GYN list something about really gentle stroking of the uterus would give better contraction than more vigorous massage. So the next csection I helped on I tried it. Just stroked it gently like rubbing a baby's back, and lo and behold, it contracted right up hard as a rock! Since then, I have done the same during third stage of vaginal birth and it works the same way. Of course there is the occasional uterus that gets a clot that needs more vigorous pressure, but this is fairly unusual, in my experience.


I check the uterus right after 3rd stage, if not firm, will gently (if possible) massage into a contraction - otherwise - leave it alone and teach the mother how to make sure it is firm/contracted and massage it herself if need be. With women I am very concerned about (i.e. previous PPH due to uterine atony; dysfunctional labor; low-lying placenta; or slightly anemic) I am more likely to massage prophylactically.


I usually give one good massage after placenta to release any clots (but not always) and then just a gentle check every so often - came on this gentleness by experience. Of course this is if all is going as we wish.


I've always felt that that hard kneading that happens after births was too hard and intrusive. I've always stroked the uterus lightly and got the same results. I don't think it is necessary to grind the uterus. Also the mom appreciates the soft touch. I've had many ask me after the baby is born, "You're not going to grind your fist in my stomach are you?" I always say not necessary.


Funny, I've been thinking about this bogginess lately and a few other thinks that we do routinely because we were told to and just watching and wondering what will happen if we didn't...I've come to conclusion re: boggy uterus that if there isn't any heavy bleeding, don't worry about it.

Again, I haven't noticed this in practice, although have had the same explanation given and as I have personally found this extremely painful, prefer to wait to use it if really indicated, not just for the measurement, but only if the bleed is actually there. But even then I don't seem to use that technique, but use my herbs or homeopathics


I'm lost (again). Are we talking immediately post placenta birth?, or later (say 1 or 2 hours or more down the road)?

I always check the fundus periodically immediately after the birth of the placenta. I do this because if there is a clot stopping up the cervix, then blood continues to fill up in the uterus and increases the fundal height without evidence of "the bleed". I have seen cases where the uterus just seemed to be not contracting well and it slowly fills up and interferes with contractions (at least that's sure what it seemed like). Sometimes, in these situations, there isn't a lot of flow until mom gets up (or until some fundal massage causes a contraction).

OTOH, of course the uterus will not always be super firm. Goodness, the way the uterus works is by contracting AND relaxing.

I totally agree that, in most all cases, the massage can be done very gently and lightly (in fact, I believe that light touch works better). I have to say that I am a lot more aggressive in certain situations (hx of pp hemorrhage), but still don't think I would fall in the rub-to-the-tailbone category. Now give me a major hemorrhage...wait, I take that back!!!


I teach the mother to feel her uterus within 15 -20 min. after the placenta. I tell her that this is one of the strongest muscle/organ in her body. That in a non pregnant state she can not feel it and now postpartum she can. It is a special time and she should take advantage of it.

Women all the time tell me thank you for telling them this. That they never new how strong it was or how quick it would shrink. This has cut out all of our PP fundal massage except for the rare hemorrhage where I sometimes have them hold their own uterus down.


I have never found it a necessary routine to massage the uterus. It is so rare a need for me that I really can't think of when I last found it necessary to do so. I probably never have.

On the other hand, I remember my first and only hospital birth where the L&D nurses suddenly without warning, and while discussing their last nights adventures on the town (admittedly, was back in 1974), began to very aggressively massage my uterus. It was extremely painful and was painful enough that I felt I had to grab at them to make "them" stop even though I was a timid 15 year old at the time. It didn't stop them from massaging me nor their conversation, though, the explanation being that that was the way to deliver the placenta.

I have seen a few nurse-midwife do the same "routine" at homebirths, but I rarely feel a need to perform this action. Why would you ladies find a need to do this as a routine, even if gentle? Just a polite inquiry.

Also, perhaps along the same lines, I am lovingly teased around these parts for my "sitting at the hole and waits" tendency and therefore I often experience, among many other things, a "prolonged" third stage. The stats forms that we have to fill in here defines a retained placenta as anything over 30 minutes (!) which makes my stats come up as nearly 98% retained placentas! I have never found them cause for over-concern (other than getting very bored), will only occasionally very gently feel the uterus to check for hidden PPH, but after checking for an hour w/o indication for further concern, don't worry about it any more and just continue to wait.

In fact, last year I was attending this birth of a lady having twins, waterbirth, 2nd stage, 1st twin = 9 hours, crowning = 1.75 hours, 2nd twin a quicky 50 m, not much crowning, followed by 8 hour 3rd stage totaling 83 labour with intact perineum. No problems, all really nice, but looong. I was reading the thread on flexing the head and thought you would be amused (shocked? disgusted? looking to deregister me? :) -- can't - I'm not registered!!) at the crowning, etc.


I was attending the Midwifery Today conference a few years back in Hawaii. One of the workshops was on preventing tears and somehow the topic of time and 2nd stage came about. The Japanese midwives became a bit confused whether they were understanding properly hearing lengths of time = 1hour, 2hours...Their protocols allow only for 1/2 hour primip, less multip! Of course, everyone was very surprised to hear this small allowance and tried to reassure them that esp. for primip, 2 hours was pretty typical. I leaned over to my fellow Aussie midwife (actually, I'm not really aussie) and whispered, "do we tell 'em about the times we sit through 1.5 -1.75 hr crowning?! Or the 9 hour 2nd stages?!" Yes, I listen to FHTs, yes I check how the mother is doing, etc. They always have the option to transfer to hospital if they choose, and it usually comes up in the conversation along the way (inevitably, there's heaps of time to discuss a lot of things!), but only once did a woman request a transfer because of time lapse; ended up being 87 hrs - 80 hours from the first VE I did after I arrived and found her 7 cm! Labour just sorta died out for sometime, but being so dilated I couldn't afford to chance the 1hr & 15m drive home to wait some of it out.


About aggressive fundal massage:

I have been doing homebirths for 20 years and I can not understand how such a barbaric practice can still be used so widely. It is very painful and borders on abuse. New moms should not be subjected to this "routine". There are so many other ways of effectively working with her in a respectful manner.


We have always checked the uterus for approx. 2 hours pp. If it is boggy then we rub it up, and show the mom how to do it. Also, if the uterus rises several fbs above the umbilicus I will do a more vigorous massage to expel clots. I was always taught that with a clot filled uterus, the mom would have more bleeding and be more prone to hemorrhage when she gets up.

I would be more than happy to discontinue this barbaric procedure if enough experienced midwives tell me it is unnecessary.


What you are doing in the immediate PP period is not at all barbaric. I am referring to the fist being shoved into the abdomen and the whole thing kneaded like a wad of bread dough. If the uterus is boggy or there is a need to express clots, then uterine massage works beautifully. My objection is to the kind of brutal massage I so frequently see where the mom is in more pain than she was in labor, done routinely, clots or no. My best defense against boggy uteri and clotting is having the mom do her own massage after being shown how as well as having her lie on her stomach and put her fisted hand against the uterus to keep it firm. Since i have never seen any of the midwives I work with at home need to do anything further, I must conclude that firm but gentle is more effective than reaming the poor woman out.


I lightly touch the uterus after the placenta has passed and every half hour or so after I check the bleeding also. If there is a steady flow, Yes, I will rub it up if it is soft and boggy. I think it is barbaric to let a woman lose more blood than she needs to.

Let's face it......if we didn't do anything that is uncomfortable to a mom, we could be in a lot of trouble......should we do away with pap smears because the speculum is uncomfortable? After all, how many of your moms have abnormal ones. How about all vaginal exams? Maybe you don't care what position the head is in and don't care if there is asynclitism or if a mom pushes on an undilated cervix. What about pit or bimanual when there is a hemorrhage? Let's hope we can get them to the hospital so that the docs can be the "barbarians" .Maybe tell a mom not to nurse just 'cause her nipples are sore. Lots of people use bottles.

I'm sorry I'm being so sarcastic, just my mood tonight. Maybe brought on by holier than thou type remarks. It's not a problem to put forth your practices, but being judgmental about other's practice is just as nasty as my sarcasm.


I too second this willingness to discontinue . . ."if"

I think there are ways & "other ways" of doing fundal massage. . . . - and some of those ways certainly do seem barbaric. I contrast what I have experienced done upon myself. My first two births were not with a midwife. And I would classify those experiences with PP fundal massage as barbaric. I have then experienced the hands of midwives two times & while they did their job, & yes "it is not comfortable" - it also was not brutal. And, even with that second midwife-attended birth, I developed a PP Strep B - intrauterine infection & was hospitalized. I clearly remember the nurse in that instance looking for my tailbone through the umbilicus.

Personally, I feel I can do a PP fundal check "gently". You don't have to just dive in there forcefully - and when you find what you're looking for, you don't need to apply more pressure just because you found it - on the other hand, if you do find a boggy uterus, I have generally found that simply rubbing with "maybe" a little more pressure works - again, I don't feel you have to rub the tailbone to do the job.


One of the things I have found that makes a difference with the comfort of pp fundal massage aside from pressure exerted is the positioning of one's hand. I have seen many nurses and practitioners go for the fundus by putting their fingers straight in towards the woman's back and this is almost always painful. It works much better to check with the side of your hand (pinky side) next to the woman and to avoid sudden motions, rather moving in a slow, fluid manner. If massage must be done, this is much less uncomfortable, and I finally realized there was a real difference after having women comment on it when I worked as a nurse at the hospital.


Funny, I've been thinking about this bogginess lately and a few other thinks that we do routinely because we were told to and just watching and wondering what will happen if we didn't...I've come to conclusion re: boggy uterus that if there isn't any heavy bleeding, don't worry about it. I started wondering after my last 2 kids where my ut was often boggy, but no heavy bleed, etc. or other probs. So now I say the same to moms, to just rub it up if there is heavy bleeding, put the baby to breast, play with your nipples, empty bladder...That seems to be working.


Also, if the uterus rises several fbs above the umbilicus I will do a more vigorous massage to expel clots. I was always taught that with a clot filled uterus, the mom would have more bleeding and be more prone to hemorrhage when she gets up.


Again, I haven't noticed this in practice, although have had the same explanation given and as I have personally found this extremely painful, prefer to wait to use it if really indicated, not just for the measurement, but only if the bleed is actually there. But even then I don't seem to use that technique, but use my herbs or homeopathics instead. Still haven't had problems as you suggest.


I am one who definitely feels vigorous massage is not indicated in all PP moms, but one MUST watch that uterus and note it's position. If it clots off at the cervix, the uterus can gradually fill, up to 2 units or more, and when she finally gets symptomatic from blood loss, it is too late to prevent a major bleed. Also, I think it is important to get her up to the BR within the hour, both to empty the bladder, but also to drop out the clots.

On another note: I once had a woman who felt very strongly about leaving the cord alone, and just waiting for the placenta to come on its own. Not a lot of bleeding after the separation gush, so I had her push a few times, no placenta, so I just sat and watched her play with the baby. After 15 min or so, I felt up at the fundus, or where I thought it should be, and couldn't really feel it. Started searching around, and finally found a big mushy mass just under the right ribs. By this time she was sweating and looking icky. Pulled out the placenta, which was acting like a cork, and 2000 cc blood followed. Scary. Other times, the clot has worked as the cork and same thing happened. So all is well and good for gentle or no massage if uterus is tight and doing its job. But to say never massage, or only use the baby to stimulate contraction can be an error that could be costly.


I agree with you as far as making sure moms are not filling up with blood. What I also find is that clots that remain at the cervix will act as a plug but also can lead to lower uterine segment atony which will lead to more bleeding, so I like to make sure there are no clots.

Sometimes it takes little to no massage and other times it takes more. Sometimes it requires evacuating the clots from the posterior fornix and cervix manually. If active bleeding ensues due to lower uterine atony, I massage the cervix in a circular motion with my examining fingers until it firms up. This works well and would be my next step in controlling the bleeding. If lower uterine atony persists I prefer methergine to pitocin in that it works by creating a tonic contraction rather than clonic and tonic. That steady tonic contraction works well on the lower uterine segment. I also like to be aware of the woman's bladder status before delivery and make sure she has voided. A distended full bladder can lead to heavier bleeding.

I was at a midwifery gathering and heard of a maneuver to control postpartum hemorrhage, whereby you take your fist and put it up in side the uterus to the fundus and then massage the fundus using your abdominal hand. Sort of a bimanual massage. Have you or anyone heard of this and does it work???


Again, I know the whys and reasons, but as I say, I've been wondering about it actually occurring and so far have not seen it so in nearly 600HBs, no oxytocics for 3rd stage, and checking myself PP for days following as well as immediately PP and while definitely occasionally having a boggy ut., no heavy bleeding, some clots, some large, but not a real problem, just according to the books in terms of existing, not compromising me. Actually, it is part of a bigger "picture" that I seem to be trying to learn to work with and that is one of staying out of the mother's/father's face while they "do their thing", which I think can be very disruptive and negative on the big scale vs. monitoring well-being and on what level, what skills (I know what we are "supposed" to be doing), what's what, etc. Just feeling my way through.



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