Saturday, 15 November 2008

Sharon's Story Part 2 - The Third Stage

In 'Sharon's Story', Virginia described the home birth of a baby weighing 12lbs. The labour and delivery of the baby was straightforward, but the third stage somewhat more complex. In this section, Virginia describes management of a postpartum haemorrhage at home, and subsequent precautionary transfer to hospital.

Forty minutes later Sharon birthed the placenta with quite a huge blood loss. All was well at this point so we all went into the lounge and Sharon breastfed her baby.
She had not breastfed any of the others and really wants to succeed this time. About an hour after her birth Sharon had another large blood loss and felt slightly clammy so I lay her down on the sofa, gave her some syntometrine and looked for my blood pressure cuff. It was nowhere to be found! I had it during labour but now it was lost. ...

I was concerned that I might have a woman who was compromised and so I called a paramedic.They arrived within 3 minutes and were the best guys I have ever met in the job. They got their BP machine, which recorded observations at 5 minute intervals.

Sharon’s observations were all normal. She then vomited and at the same time passed a huge amount of blood and clots.I felt it was appropriate to give ergometrine IM and commence 500ml gelifusin and then 1000 saline.
Sharon felt fine and all her observations were fine. The Paramedics remained for nearly 2 hours. They helped without taking over and were a pleasure to have around.

Would it be usual for a midwife to take blood for cross-matching at this point, or is that something the hospital would prefer to do themselves if necessary? My understanding is that transfusion of actual blood would not be done in a rush anyway...

Correct. If a woman was compromised they would not rush the blood in rather that she would receive fluids first and that is the first thing one would do. Bloods for cross match can be done later. We did not leave the house for 2 hours approximately - why would I be rushing to take blood? I might do that only in a dire emergency, but not in a non-urgent situation like this. Paramedics don't take blood following a crash, do they??

I felt that Sharon did not really need to transfer and instinctively felt that the large loss which, in all I estimated at 1500mls, was due to the large placental site and yet again normal for her as she was not compromised.However having discussed it with my supervisor I transferred her. I think covering ones behind was discussed!!!

- In the reflection, you say that Sharon lost an estimated 1500 ml of blood and yet was 'fine' - how could this be, when 1,500 mls would be a very serious loss? It sounds like you were erring on the side of caution in your estimate.

The issues around the third stage were a catalogue of unfortunates that stacked up. She had a large placenta, which was to be expected having had such a big baby, and so the blood loss when she birthed the placenta was on the higher end of normal, but she was fine.

My experience of physiological third stages is that blood loss is initially higher than in managed 3rd stages (which the evidence backs up), but that a woman often has another gush of blood following breast feeding, often when she stands up to go to the loo for the first time having been resting for a while. I always put protection on the floor next to where she will stand in anticipation of this. She then will pass urine and the blood loss settles. I always tell women that they may also feel faint and woozy when they stand for the first time too. This happened to this client exactly this way, but in consideration of the higher blood loss I acted as per standard practice and administered syntometrine. This was, as already highlighted, my “think ahead philosophy” of not wanting to interfere, but also not wanting to wait till I may have a compromised client. It is correct practice to check a client's observations in this instance.

Following the birth I had taken Sharon's blood pressure and the observations were normal but I wanted to re-check now. I was gobsmacked that I could not find my BP cuff because I had it an hour earlier. (I found it a week later rolled up in my fetal monitor bag; I had been tidying up my equipment in preparation for when it was time to go and must have put it in by mistake)

My only recourse was to call an ambulance. I HAD to presume abnormal. However, when they arrived all obs were normal and that was a very short time after.

Sharon vomited - does that mean that she was really ill?

Syntometrine has a common side effect of vomiting and that is why Sharon vomited. If she was critically ill, her observations would not have been normal, but again, when she vomited some blood clots were pushed out. As a further precaustion I gave ergometrine. In all honesty I think I gave more oxytoxics than she needed.

So now I had ambulance guys there. It just adds to the story to make it sound dramatic, but there was no panic - the client was chatting with us all and the fluids we gave were making her feel fine. Just because fluids were administered does not mean we were seriously worried - after all, they are put up at the drop of a hat in labour wards everywhere. The ambulance guys would have tried over-riding me if they thought I was acting irresponsibly as they deal with abnormal all the time. They would more likely presume abnormal than otherwise. Yet they were laughing and joking and quite happy to wait around while we deliberated.

Sharon did not want to go to hospital and I, in my heart of hearts, did not really believe she needed to. However, I spoke to my supervisor of midwives as is the correct thing to do in any case where events are unexpected or "different" or worrying or for support for me. My supervisor of midwives, despite agreeing with me that she was probably fine, thought I should protect myself from medical criticism and get her checked over.

The baby was much bigger than anticipated, and one of the risk factors for post-partum haemorrhage is a large baby and so of course that was in my mind.The evidence suggests that blood loss is vastly UNDER estimated, on average. It is hard to estimate blood loss when some is going down the loo with the placenta (to be fished out later), some is in the water and some on sheets and towels. I tend to overestimate to compensate for that . It was certainly overestimated in this case as the HB dropped from 11.5 at the last FBC in pregnancy to 9.8 following birth. Therefore the total blood loss was probably around 1000mls.

[Ref for blood loss usually being underestimated: there have been a number of studies on this, but one of the most recent is:Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions by Bose P, Regan F, Paterson-Brown S, in BJOG. 2006 Aug;113(8):919-24.]

- Some midwives say they prefer to look at the mother's condition before diagnosing PPH, and not just the measuring jug - what do you think?

PPH needs re-evaluation in the UK in relation to the definition of PPH. 500mls of blood is not a realistic amount to give such a serious label as 'post-partum haemorrhage' and all that label tells you. PPH written in a woman's notes could have serious consequenses for her - that is why so many underestimate. The woman shoud be loooked at to identify if she has been compromised by blood loss rather than just looking at the written notes. We give almost that amount when we give blood and are sent on our way with a cup of tea. In Holland the definition of PPH is 1000mls of blood. Women are able to withstand quite large blood losses due to haemodilution in pregnancy. Moreover, everything is relative to the size of the baby. This woman would have had a higher blood plasma volume due to the larger placenta needed for the larger baby, therefore could withstand a larger blood loss. What would be a better definition of PPH would be any amount that compromises women. Again you can only use that definition if you are looking after women as individuals and of course large organisation like the NHS can't do that. There has to be a threshold for a definition of PPH, but the UK one is too low.

When I was an NHS midwife I observed that many women's notes had a written estimated blood loss of 450mls; obviously it would be very difficult for the midwife to discriminate between estimated blood loss of 450ml and 500ml, but they did not want her to have the PPH label on her notes. If a woman is defined as having a PPH it has implications for how they are viewed postnatally and for future pregnancies. I do not have to consider this as I make individual decisions based on individual cases. I always look at a mother’s condition as well as the total blood loss.

When we arrived the same midwife was on duty and Paul quite firmly ordered her out of the room! Sharon was then cared for by a lovely midwife. However yet again that medical model reared its ugly head and they wanted to do tests on the baby. Blood sugars and IV antibiotics!
Sharon declined and stated that she had come in to be checked over not the baby and please hurry up as she wanted to go back home. She was all perfectly normal with a well contracted uterus, normal observations and lochia. She had a couple of hours of syntocinon as a precaution and then we all went home.

She has a haemoglobin of just under 10 (so probably a bit lower in reality) but is feeling great and tucking into steak and broccoli. Her big beautiful baby is named Tulah and weighed in at a whopping 12lbs. Tulah is feeding on demand, 3-4 hourly. Perfect. Sharon is giving up having babies now.

In this case, as I understand it, Sharon transferred to hospital to be checked over:

"She was all perfectly normal with a well contracted uterus, normal observations and lochia. She had a couple of hours of syntocinon as a precaution and then we all went home. "
So, if Sharon was checked on arrival and found to be OK with her uterus already well contracted, why was she given Syntocinon?

The doctors who saw Sharon at the hospital wrote in the notes that all was well, everything normal etc etc, but I had reported a 1500ml blood loss and he could see a large baby so I think any doctor would do the same as they always err on the side of abnormal and follow a medical model of care. Syntocinon is usually given in that instance. The underlining principle is that the uterus may relax and the woman may bleed again.

If I had not mislaid the BP cuff maybe I would not have transferred her and then the “story” would not have read like it did....More likely it would have said “the client had a large blood loss, as to be expected, that settled with precautionary oxytoxics with no compromise and all was well”

- Sharon declined to have her baby's blood sugars checked when she went to hospital. Can you explain why a blood sugar test might be suggested for a large baby? If you don't have the test, how do you know the baby's blood sugars are OK?

Big babies born to diabetic mothers are at risk of neonatal hypoglycaemia. If a woman has diabetes she will more likely grow a big baby who gets used to high sugar levels in utero, then when the baby is born the blood sugars plummet and the baby can become hypoglycaemic. A big baby is often presumed to come from a woman with diabetes, but our client had been tested and did not have it during pregnancy. Big babies from nondiabetic mothers are not a high-risk group; in fact, one of the highest-risk groups is premature babies and those which are of low birthweight.
Symptoms of hypoglycaemia are primarily a sleepy baby, irritability, jitteriness, feeding problems, and floppiness, amongst others. The baby showed no such symptoms, and the client did not want her baby subjected to a blood test for no reason. Furthermore, initial treatment for low blood sugars is regular feeding; we knew the baby had received a long recent breast feed and was alert and well. Therefore, apart from ticking a box, what was to be gained from taking blood from the baby?

[Readers wanting to know more about neonatal hypoglycaemia may find the following sources useful: World Health Organization review on Hypoglycemia of the newborn, 'GP Notebook guide to neonatal hypoglycaemia, and Babycentre UK's info for parents on low blood sugar in the newborn. ]

Thanks Virginia.

This story continues in the next post, on Midwifery Supervision and Independent Midwives, where we discuss Virginia's consultations with her SOM over this case.