postpartum hemorrhage

[Melarina]

I experienced severe PPH immediately following DD's uncomplicated and relatively easy vaginal birth - I needed 8 units of blood, long spell in OR, lots of other fun stuff.

DH and I are considering the possibility of DC #2 (not till DD is over a year at least, but we're talking and thinking, since I am 37 and he is 42.) I am concerned because as much as I want a second child, I want DD to have a mom, and the doctors told me I came close to dying.

I had a lot of bloodwork done during the months after the birth, including assessment by a hematologist, and nothing came up unusual. We've talked a lot with my OB and came away not sure what to think. She said they did not know why it happened. We know there are no guarantees, but I'd like more information and perspectives.

Do you know anyone with PPH who had other children? What explanations for PPH have you heard? TIA!

[american_mama]

I know three people who have had a post-partum hemorrhage of some sort. I have thought about their various situations a bit myself, so I will present them in all the detail I know.

The one I know the most about was a friend who hemorrhaged right after her son's uncomplicated vaginal birth, and required at least two transfusions and was in the OR being prepped for an emergency hysterectomy when the OB got her bleeding under control. In her case, the suspected cause was placental accreta, when the placenta embeds in the uterine wall and does not detach. Her OB manually removed the placenta after it did not detach post delivery, and I believe the hemorrhage started after that. I sometimes wonder if the manual removal hurt more than it helped, but I really have no idea. A sample of the placenta was supposed to be sent to the lab for analysis, and my friend, even in her incredibly low blood pressure/wondered if she was dying state, specifically remembers the ob asking for that to be done. But it wasn't done, so they don't have a lab report to know exactly what caused the problem. Her OB gave her some statistics about the likelihood of this re-occurring in a future preg and while they weren't small, I think they were well under a 50% chance. (My friend had no risk factors for accreta: no previous C section or uterine surgery, nothing). Her OB said that in a future delivery, they would have blood typed and matched for her, ready to go in her delivery room, and that everyone would be mentally and physically prepared for the possibility of hemorrhage. My friend is considering a third child.

I think I read on another message board that some women have ultrasounds that detect blood flow through the placenta and which can help determine if accreta has occurred. You might ask about that.

I know less about the two other women I know who hemorrhaged. One had a homebirth and lost a lot of blood, and was just above the level of hematocrit? hemoglobin? that her midwife would have transferred her to the hospital. My friend felt weak for a long time afterwards, but recovered well.

I know the least about the third situation, but I believe her OB applied traction to the cord after delivery to encourage the placenta to detach. Instead, the cord snapped off and she hemorrhaged. Again, I am not sure if the cord traction was a good idea in this case, or maybe it's about too much traction being applied. I don't know if that friend required a transfusion or not. She is a very thin, pale, borderline vegetarian person and I wouldn't be surprised if she was anemic before the birth, which might have made it harder to recover from dramatic blood loss. She had a scheduled c section for her second child, not sure why.

I hope you get some answers and I will be curious to read any other replies from people who have BTDT.

[Melarina]

Thank you so much for this information - I really appreciate it. Hoping to get as much info as possible on this. I know it's different for everyone, but various perspectives really interest me, Thanks again!

[DrSally]

I had secondary PPH, exactly 1 week after DS was born. Lost about 500 cc of blood (as much as during birth), but didn't need a transfusion b/c I still had some "reserves" from the pregnancy. It was prob due to a number of factors, vacuum extraction and traumatic birth with extensive tearing, having a boy (I believe), Asian ethnicity...I'm foggy on these, but I think they were all risk factors. I'm sorry you had such a terrible experience. It is strange given that your birth was relatively smooth. I know someone who had PPH each time and was give methergin right away after birth of each of her 3 children. Something about her bladder being in a strange position compared to her uterus?

ETA: I was very weak afterward for at least a week and needed to hire help, but was fine afterward. Like pp, I've heard that remnants of the placenta left over or other problems with the placenta can cause PPH. I had an ultrasound done at the ER and they didn't see anything, so I didn't need a D&C. Did your OB mention anything about the placenta? What about an elective CS. I have no idea, but would t at circumvent the prob if you really wanted more kids?

[tnrnchick74]

I have no firsthand knowledge of PPH...but I would HIGHLY suggest discussing this with your OB BEFORE you get pregnant. They might want to do some bloodwork or even send you to a specialist. A scheduled c-section might be indicated. And if they KNOW you are more susceptable to PPH, there are meds they can give to try to prevent it. You will probably be a high risk patient than your first pregnancy.

I think, though, you have a good chance of having another good outcome...but I'm not a doctor!

[Melarina]

Thank you all so much for the information; I am really grateful for your time and advice.

I thought of a couple of other things about my situation that I wonder whether they played into the hemorrhage at all. My OB did an ultrasound and also a D and C because they were concerned about the placenta, but they found nothing placenta-related. During the past couple of months they've done all kinds of clotting and other tests on my blood but everything came back normal. I had slightly elevated amniotic fluid at 36 weeks. I was induced with Pitocin at 38 weeks because they thought DD was going to be large (she ended up being only 7 lb 2 oz). I was dilated to 10 for a good hour or more before they had me push. They said this was to let the baby work her way down more but I wondered if it had more to do with getting the doctor there - she showed up really close to the delivery. I was induced at 7 am (went in to the hospital at 4 cm) and had the baby at 1 pm. I had spotting throughout my pregnancy which was never explained - at first the placenta was close to my cervix but that moved up by 20 wks.

My grandmother and aunt each had hemorrhages during surgery, but not during childbirth (they had four and nine babies respectively.)

I have wondered about a c section too if we have a second child, but since they don't know why I hemorrhaged, I wonder if that would have just as much possible chance of hemorrhage as a vaginal delivery?

I realize it very well may be a question that never gets answered, and it wouldn't really matter to me except for the interest in the possibility of DC 2.

Thanks again for any thoughts you can share!

[DrSally]

I would def mention your family history of hemorrhages, that may have something to do with it. They may have preventative measures or medications now. Maybe a perinatologist might have more experience with these issues and could offer some insight. ITA with pp, though, to discuss it before becoming pregnant again. Good luck!

[american_mama]

What does you OB say about the possibility of a repeat hemorrhage with a second child and, even more importantly, about their ability to treat it? What does the OB say about the success of a C section in avoiding a hemorrhage? My friend with the possible placenta accreta said that her OB said that while the situation was very serious (the OB mentioned that she hadn't seen anyone hemorrhage like that since residency), they were in the hospital, well-prepared for the situation, and she was not in danger of dying. Obviously, a hemorrhage is life-threatening, but her OB focussed on the competency of the hospital and staff rather than the direness of the situation. It might be a bit of the glass being half full vs. half empty, but you might consider both perspectives.

Also, another perspective. Two of the three people I mentioned hemorrhaged with their second child, but not their first and, to my knowledge, the friend with the elective C section did not hemorrhage a second time. You might be just inverted in what happened to you (i.e. it happened with your first child) and your second delivery might be smooth.

Lastly, I hesitate to mention this, since PPH is very serious and I am not a doctor. But you might want to research if there is any relationship between certain interventions (like induction, or certain induction meds) and chances of a PPH. On the one hand, with you, you were dilated to 4 cm at 38 weeks and had the baby in about 7 hours, which is hardly a rough induction. On the other hand, the estimate about baby size was clearly way off, making that reason for induction very suspect. Also, I don't know if nursing immediately after delivery can stop something as serious as a hemorrhage, but it does help the uterus contract, so that might be something to do next time, if you are able.

Pubmed is a good place to search medical journals for reputable information, see http://www.ncbi.nlm.nih.gov/pubmed/.
Here are two articles I found in a quick google about PPH.
http://www.emedicine.com/emerg/TOPIC481.HTM
http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnant/postpart.cfm

[Melarina]

Thank you all so much for these thoughts and ideas. A couple of things -
My OB said that while it's possible that heredity played into the hemorrhage since all my bloodwork came back normal it could be something they don't know how to diagnose yet. She said they don't know what my chances would be of hemorrhaging again.

One thing I forgot to mention - OB said that anesthesiologists have told them about seeing more bleeding with epidural placement in women on DHA/RHA supplements - that was in my prenatal vitamin, and I did have a lot of bleeding at the epidural site. Maybe that has nothing to do with it, but who knows.

It sounds like I should go back and ask her point-blank what my chances would be of surviving another hemorrhage, and what a c-section might do.

I, too, have wondered about the role that induction with Pitocin might have played in this. I asked my OB and she was noncommittal. Then again, she was the one who suggested induction, so, hmm.

Thanks again so much for the responses. It really means a lot to me!

[tnrnchick74]

I would also ask for a referral to a high risk ob/perinatologist to get that experts opinion as well!

[kozachka]

A good friend of mine had a bad case of PPH. She first hemorraged two days after delivery, right around the time they started supplementing BFing with FFing. She had two trasfusions and was hospitalized. They never figured the cause. She was not induced and had unmedicated delivery. She had another child in less than 2 years after her first and did not hemorrage. Her second pregnancy was considered more high risk than the first.

[SnuggleBuggles]

When you are induced it sends more blood (possibly than normal) to the uterus (uterine hyperstimulation) and that could increase the risk of PPH. I included it in the info I wrote up for labor inductions for my old labor board but I don't seem to have a great link on it saved. Some of my info came from books, like Henci Goer's "The Thinking Woman's Guide to a Better Birth."

http://www.motherfriendly.org/Downloads/induct-fact-sheet.pdf

"In addition to the risks that normally occur with labor and delivery, inducing cervical ripening and labor adds the risks of uterine hyperstimulation, fetal distress and a greater likelihood of postpartum hemorrhage."
http://www.aafp.org/afp/990800ap/477.html

Pitocin is included under risk factors for PPH:
http://www.fpnotebook.com/OB/Bleed/PstprtmHmrhg.htm

GL on getting good answers...and a safe birth next time. :)

Beth

[AngelaS]

I hemorraged after #2 but had no problems after #3. :)