QuestionI suffered a postpartum hemorrhage with my second pregnancy. I am nearly
8 weeks pregnant and am wondering what preparations or implications there
might be because of this. I was told by my then OBGyn to make sure anyone
in the future responsible for my obstetrical care should I have more children
be well aware of my history. What can they do to prevent this happening a
second time? I'm wondering if I might need a cesarean this time.
AnswerDepending on what the cause of your hemorrhage was, there are a number of things you and your provider can do to help prevent a recurrence. I assume you were checked for blood clotting disorders and came out okay. The two other main causes are rushing the third stage delivery of the placenta, and an extended/augmented labor that exhausted the uterus.
The first situation usually involves cord traction or even manual removal of the placenta. Many doctors get impatient after the baby is born, but physiological delivery of the placenta can take up to several hours and still be within normal. Cord traction, or pulling on the umbilical cord to pull the placenta out, can cause the placenta to prematurely separate from the uterus. When the placenta separates before the uterus has begun to shrink, the connecting blood vessels are left open and bleeding, and blood loss can become heavy very quickly. When the placenta is manually removed, pieces can remain behind. These pieces can prevent the uterus from contracting properly, again leaving the placenta site an open, bleeding wound. If either of these happened during your delivery, discuss with your current provider the option of waiting for a natural delivery of the placenta, with no cord traction and no rushing, even if it takes a while.
The second situation I mentioned, an exhausted uterus, is caused when your labor is induced or augmented, but can also occur if the second stage is prolonged or involves coached pushing. When you use pitocin during labor, you interrupt the natural cycle of hormones the body uses to regulate itself. You force the uterus to contract longer and harder than it would naturally, and you disrupt the feedback loop of stress hormones and endorphins that would provide the extra strength and endurance needed. When you use coached pushing during the second stage, as opposed to only pushing when your body pushes on its own, you are again wasting energy needlessly. Both of these things can wear you and your uterus out, causing the third stage to falter when the uterus needs to contract quickly and cut off the blood supply to the placental site. If either of these was the case with your labor, discuss with your current provider the option of allowing natural, physiological labor to progress without augmentation, and pushing only with the urge. It may take a little longer, but natural labor does not run on a time clock. As long as you and your baby are not in distress, there is no medical reason to speed up your contractions or force you to push when you do not feel the urge; you will only be increasing the risk of a recurrence.
I would not consider a c-section as a preventive measure for postpartum hemorrhage. If you did have a clotting problem in your blood, a c-section could be disastrous for you, as you have an entire abdominal incision, through skin, fascia, and muscle, as well as the placental site, and all of these will potentially be bleeding out of control. If your hemorrhage was the result of a mechanical problem as I outlined above, you should be able to prevent a recurrence.
Congratulations on your new pregnancy, and happy birthing!
