QuestionQUESTION: With my first pregnancy I did not have a midwife. The delivery went well, without a hitch at all. It was as easy as pie. However, 12 hours after giving birth I hemorrhaged. suddenly I find myself pregnant again and obviously, I'm terrified. I was wondering if you would recommend I have a doctor PLUS a midwife? Would you say a midwife might be able to help protect me in some way that doctors might not be able to? In my scenario the problem was unidentified. They said they didn't know why I was still bleeding because I was not "boggy". I did tear. I do have endometriosis and cysts. would a midwife's knowledge and expertise benefit this situation?
ANSWER: Dear Teg,
First of all, congratulations on your pregnancy!
It's hard for me to guess what the reason for your hemorrhage is from here.
There are a few reasons why it may have happened.
One is a retained piece of the placenta, usually caused by the caregiver pulling on the umbilical cord after the baby is born, to hasten the delivery of the placenta. When that is done, sometimes a small piece of the placenta tears off and stays in the uterus, keeping it from contracting tightly, so the capillaries that were open during the pregnancy to keep the placenta attached can't close fully, and the mother keeps bleeding. Sometimes the small piece gets passed unnoticed during the bleeding, and the mother stops bleeding, but no one figures out what it may have been.
Boggy means the uterus stopped contracting, and in your case, it sounds like it was hard, like it is supposed to be, but something inside may have still been opened, so you were still bleeding.
Sometimes the bleeding is from a tear on the cervix, that could also go unnoticed, if it isn't large enough.
Also, sometimes the bleeding is actually from the site of the tear, but because the bleeding is so heavy, no one thinks to look there! They just assume it's internal.
I would recommend getting a full copy of your medical records from your OB. It may cost a bit, but it's worth every penny. Sometimes they write things there that they don't tell you.
I would always recommend going to a midwife, (especially one that has her own practice, not part of an OB's) even just for a consultation, to have her read your records and see if she would have handled your situation differently.
The difference between a doctor and a midwife is often simply that the midwife treats you as a person, and really listens to you, so that less details get overlooked.
Of course there are doctors like that, too. And there are also midwives that aren't all that great.
But seeing a midwife now, or even another OB, would be a good idea, simply to get a second opinion.
There are things you can do to prevent or help stop hemorrhage, that doctors may not do, but midwives (CPMs or CNMs, and in some states, CMs) would.
First of all, don't allow your caregiver to touch the cord after the birth, until they see it wriggle in a way that means that the placenta is fully detached, and is ready to be expelled. That way, there is no risk of them tearing it.
Refuse to be induced (or augmented) with Pitocin or any other drug, because it hyperstimulates the uterus and sometimes that causes it to be unable to contract well after the birth, causing hemorrhage.
Massaging the uterus directly after birth, gently but firmly, helps it contract and seal off all the open blood vessels. You can even do this yourself.
Breastfeeding immediately after birth (preferably before the baby is dried off and taken away to be weighed and measured) is extremely healthy for both you and the baby, as it causes you to secrete your own oxytocin, causing the uterus to contract and close, and promotes bonding for both of you.
http://www.youtube.com/watch?v=auVmnvwNUOE
Keeping the bladder empty during labor and after birth is very important, since a full bladder prevents the uterus from contracting fully and efficiently.
Drinking Red Raspberry Leaf Tea is said to strengthen and tone the uterus, in preparation for a healthy birth. It is recommended to drink it during pregnancy.
There are also herbs to help prevent or stop hemorrhaging that midwives may use, that doctors probably wouldn't.
Please let me know if you have any other questions.
I hope this upcoming birth is everything you are hoping for.
Very best of luck,
Sheva
---------- FOLLOW-UP ----------
QUESTION: Hi, I do have a few questions now that you've answered me:
#1. I read that there's an ongoing dispute as to whether it's better to let the cord detach itself or whether to pull it... I read it when I was concerned about bleeding. Why do you suppose some people argue it's better to pull it? what might a down side be for leaving it in there until it detaches itself?
#2. You said no drugs such as pitocin. I could be wrong but isn't pitocin the one to help a woman clot better? What does it do, if I'm wrong. I ask because they told me this time around since they know I'm at a higher risk of hemmoreaging that they'll give me the drug to help me stop bleeding faster right away. Last time the administration of a drug like that was what actually STOPPED my bleeding. why do you recommend no drugs, when without drugs last time I bled until they gave me drugs?.....and
#3. Does an epidural count as a drug you wouldn't recommend? I got it last time and I was glad I did because I ended up breaking my tailbone when my daughter came out and THANKFULLY didn't feel it happen. I sure felt it a few hours later but it was nice not having that moment. I vowed after that there was no way I wouldn't get another one, just in case. and lastly:
#5. as a matter of fact I couldn't drain my bladder - you're right...I had a catheter in but they didn't realize until I hemorrhaged that it wasn't draining properly. I am TERRIFIED it will happen again but it seemed like the nurses and everyone didn't much care to keep checking it after I was finally stable again. I had to keep buzzing them to ask if it was draining. They'd leave me along for literally like an hour or two at a time. If a midwife was there would she check on my more often?
I ask these questions not to say I don't trust your opinion or to cause waves...it's just that it's so hard when I hear conflicting advice I want to hear not only everyone's personal advice but also what they say to the arguements their opposition has against them, as in "how do you explain this? how do you explain THEIR point of view". I go it so I can get a better grip which advice I think is more thorough. If someone doesn't have a rebuttal to their argument against the oppositions attack, I'm less likely to take their opinion seriously. For me it's important since I feel like my life literally hangs in the balance of who I choose to believe is right. I'm not trying to be a horrible person for asking, I'm just trying to make sure I don't end up dying! One side says drugs will help save me, the other side says drugs might kill me - I hate those sorts of situations! I appreciate all your advice you've given me so far and you're kind way of delivering it. Thanks for putting up with this one last inquiry!
ANSWER: Dear Teg,
First of all, you are NOT a horrible person for asking.
The smartest thing you can do is ask and understand. If anyone, doctor or midwife, tells you that you shouldn't be asking, or 'not to worry, I'll take care of it', run as far and fast as you can, and find another caregiver.
It's your body, your choice.
I'll try to answer your questions in the order you asked them, so I won't skip anything.
I have never heard that it is better or safer to pull on the cord. When pulling on the cord before the placenta detaches fully, there is ALWAYS a risk of either tearing the placenta, or even turning the uterus inside out and pulling it partway out of the vagina (called prolapse - rare, but it can happen).
It is common practice to tug gently, to see if it is detached, but sometimes caregivers get rough and pull too hard.
It is not even necessary, since if the caregiver is watching the mother constantly, s/he will see the cord do a little jiggly dance at the moment that the placenta fully detaches, and then pulling is safe, or, better yet, the mother can give a little push, and the placenta will come out.
The downside to leaving it in too long (doctors want it out within a half hour, midwives would give it longer, as long as the mother wasn't bleeding or having any other problems) is that if the uterus is boggy, and not contracting well, the placenta won't detach itself, and then the caregiver might actually have to go in and detach it by hand. But that's uncommon. Remember - if it doesn't come out immediately, it doesn't mean it won't come out soon. Wait until there is a problem before treating it.
Pulling on the cord so you won't hemorrhage doesn't make sense, since pulling on it can actually CAUSE the hemorrhage.
(I learned - the most important thing a caregiver can learn to do with his/her hands is to sit on them. Sometimes wait and see is a better approach then getting more aggressive. Don't treat a problem until there is one.)
When I said no drugs like Pitocin, I meant that you shouldn't use them to induce or augemnt (make it stronger) labor. Pitocin is a synthetic drug that mimics the body's ocytocin. It causes uterine contractions. If used to induce or augment, it will often cause stronger contractions than the uterus can handle, so that after the baby is out, the uterus is so tired (atonic) that it cannot effectively contract and tighten, and that can often cause hemorrhage.
When a mother is hemorrhaging after a birth, most caregivers will correctly (as in your case) use Pitocin, or even stronger, Methergine, to force the uterus to contract, since the hemorrhaging means that the uterus isn't doing it on its own. In your case, since it worked, that means that your uterus wasn't contracting properly, and that the drug's contractions did the trick.
I definitely wouldn't say 'no' to Pitocin during hemorrhage. I meant not to use it during labor.
Epidural is a tricky one. :)
There are risks and benefits to an epidural. The challenge is to weigh the risks versus benefits, as it pertains to your specific case, and decide (YOU make this decision) which choice is better and safer for you and your baby.
If you want to read it, here is a list of the risks and benefits of epidurals. Some of the risks are more common than others, but here is one that I find is pretty complete.
http://www.midwife.org/siteFiles/news/52.3_May-June_Share_With_Women.pdf
here is another, longer list:
http://www.gentlebirth.org/archives/epirisks.html
To address the broken tail bone, sometimes (not always) the reason for tearing or breaking the tail bone is the position that the mother was in during the pushing phase of labor.
The worst position for the mother (but the easiest for the caregiver) is when the mother is on her back, with her legs in stirrups or being held by nurses. The birth canal is a canal of very stretchy muscle and skin (the vagina) inside another canal of bone (the pelvis). Inside the pelvis, at the back, the mother's tail bone curves forward slightly and presses into her vagina. The tail bone makes up the back of the birth canal. It is attached to the hipbones on each side by ligaments, so it can move, a little bit. But if the mother is on her back, the tail bone is pressed tightly into her vagina, and can't move out of the way, since the bed is blocking. So sometimes the baby's skull has to break it to get it out of the way in order to come out.
And even if it doesn't break, if the mother is on her back she has to push 'uphill' in order to get the baby up over her tail bone.
The best and most natural and effective way to push would be squatting facing the caregiver or squatting with her back to the caregiver (holding on to the head of the bed that is pushed into a sitting position). This way gravity helps the mother, and also, when the baby's head gets to the mother's tail bone, it will just nudge it out of the way (which it can't do if the mother is lying down) and keep coming. (Point of interest - the hieroglyphic for 'birth' is a squatting woman.) Squatting also opens the mother's pelvis by approximately 25%, which means pushing will be that much easier.
If not this position, then lying on her side still saves the mother from battering her tail bone, since it can still move if she's on her side.
It's very possible from your statement about the catheter that the full bladder (and therefore, their lack of care) is what was causing your hemorrhage.
A good midwife wouldn't leave your side for a while after the birth, and for most of the time during the labor, as well.
I think I should add here that the catheter was in place because of the epidural, so it could be that the hemorrhage wouldn't have happened at all had you been able to feel your bladder. I'm not blaming you, I'm blaming their lack of attentiveness. 'Output' is on of the things they should have been monitoring the entire time, and their inattentiveness had a very dangerous outcome.
Personally, because of the careless 'care' I got in the hospital the first time, I have planned home births, with a certified nurse midwife. She comes when I go into labor, and doesn't leave my side (unless I ask her to) until about 2-3 hours after the birth. That's the kind of care every woman deserves. My second was planned for at home, but ended up in the hospital because she came early. My midwife still stayed at my side the whole time.
So it matters more WHO you choose, not where.
If you do go with a midwife, research her first, ask for references, and find out about her bedside manner, since that will tell you whether she will listen to you when it counts.
Feel free to ask more, I love when a mother asks about her care and health - it's a great thing.
You're a fantastic mother for doing all this research. It's your life and your baby's, so keep asking.
Have a great day,
Sheva
---------- FOLLOW-UP ----------
QUESTION: LOL, Okay you were right.....one more set a questions. You're the only person to give me clear advice and explain things and you bring up a lot of good points.
I had actually planned on NOT delivering on my back, as you mentioned but the doctors in the hospital make you. Before going into labor they make a big deal about saying you can do it whatever way you want, but me and several other woman I know were told we had to do it that way. It made me mad but I wasn't in a position at that moment to fight it, obviously. Maybe it was also because of the epidural. That will be a hard one to make a decision about. I'd origionally wanted to go natural but I got to 8 cm dilated with ease until one my my cysts started giving me major grief. It didn't stop hurting even when the contractions would subside so I went with it and as I said I'm glad I did. I'd be afraid that if I went for a hospital birth again they'd force me to lay on my back and it might, again, cause a break and there would be NO way I'd go through that without an epidural. That bring me to my other questions which is this: Would you say hemorrhaging at the hospital is safer than hemorrhaging at a home birth? I mean if an emergency hysterectomy was needed or a drug administered to help stop the bleeding what do the home birth people do? Are there more home birth deaths than hospital ones? as I said I hemorrhaged 12 hours after birth so would a midwife potentially stay THAT long after, or more? MY concern with a hospital is that they forced my position, they DID give me a drug to help the labour along (I had gotten to 5 cm dilated and stopped. The baby was, at that point, turned the wrong way. I knew she was I could feel her but they assured me if we gave it time she'd likely spin around, and she did). I was stuck at 5 cm for 8 hours when they gave me the drug. O and my water also had not broken at that point. they did that too. When is it necessary to have a drug like that and when isn't it? I'm afraid if I'm at the hospital I'll be too afraid to not have an epidural. Yet I'm afraid of the home birth because if it turns out I'm hemorrhaging for some other reason and it begins hours after the birth again I'm afraid I'll be a goner. What would you personally recommend for my situation?
AnswerDear Teg,
Hi again! :)
First of all, the best thing you can do, if you decide on a hospital birth, is to hire a doula - a birth coach who will be there for you throughout your labor and birth. She can advocate for you and fight for your rights, while you are busy laboring.
Studies are showing that having a doula at your birth actually lowers a lot of risk factors and makes you safer.
Introduce her to the staff as your doula, and tell them that if she speaks up, it is at your request.
Also, have your husband speak up as your advocate, as well. Tell him what you want, so that at the birth, he can speak for you, if necessary.
A good, practical book to read is "Creating Your Birth Plan" by Marsden Wager.
Two other books that are more technical but very well written are "Pushed" by Jennifer Block and "Born in the USA" by Marsden Wagner.
"The Doula Book" By Marshal H. Klaus is very informative as well.
Getting back to your questions, yes, a lot of doctors use this 'bait and switch' technique, where they tell you they'll do what you're asking, but at the birth, not so much...
You have a right to birth in whatever position you want, and 'hospital policy' can't stop you, really. So if your doula and husband hold you in the position that you want, the doctor can't force you to change.
And just so you know, if he or the nurses try, (which I've seen) you can tell them that you are aware that touching you without your permission is legally considered battery and/or assault in the medical world, and that you will be speaking to the hospital administrator, etc, if they don't respect your personal space.
A midwife will often be able to turn a backwards baby, so perhaps the Pitocin wasn't necessary after all.
You ask me for my recommendation, so here is my feelings on the situation you presented:
Labor works like pulling on a turtleneck. The turtleneck being your uterus and the neck of it is your cervix. The person trying to wear the turtleneck is the baby.
The uterus pulls upwards, and opens the cervix by pulling it against the baby's head. So if the baby's head isn't centered correctly (called asynclitic), the cervix won't dilate well.
So the quickest, least painful and most effective way of getting a mother to dilate well is to make sure the baby is straight, which good midwives are very skilled at doing. They put two fingers inside the vagina and feel for the baby's fontanel, and nudge it so that it's centered over the cervix.
Many doctors and some midwives don't consider this idea because they can use drugs and cesareans.
The bag of waters makes a cushion around the baby. If the baby is positioned wrong, the cushion of water makes it easier to turn the baby. Once it's broken, the baby often stays stuck in the wrong position. So I wouldn't recommend breaking the water, especially when the baby is positioned wrong. (There are also other dangers with breaking the waters, one being that the bag of waters is a barrier to germs and once it is broken the baby is not protected. Another one is cord prolapse, which is when the cord gets pushed into the vagina with the rush of water coming out. This makes the baby's head press against the cord, effectively cutting off its own oxygen supply, and necessitating an automatic c-section to save the baby's life. All because the water was broken and shouldn't have been. So sometimes life-saving cesareans actually wouldn't have been necessary if the doctor hadn't already done something else...)
Pitocin is necessary when birth is a safer alternative to continuing the pregnancy, for either the mother or the baby. For example, if the baby isn't growing well inside, despite the mother changing her diet and eating well and taking vitamins etc. Or when the mother is sick, and being pregnant is making her sicker, and it is safe for the baby to be born.
It is rare that a mother hemorrhages so long after the birth, and in your case, was probably due to negligence. You can get your records and describe your experience to another birth professional, but, unless they have some sort of allegiance to the OB you used the first time, I suspect they will agree with me.
The likelihood of a woman needing an emergency hysterectomy after a natural, un-drugged vaginal birth with no instruments like a vacuum or forceps used, and where the mother was allowed to push at her own pace and the cord wasn't tugged on is practically zero.
Drugs to stop hemorrhaging are carried by every home birth midwife, and if you do decide to hire one, you should ask them to be sure. I believe some of them even prepare the syringe beforehand, and have it on a tray so there won't be even a second's delay in administering it if it becomes necessary.
In your case, I would recommend that you educate yourself as much as you can. Don't read "What to Expect When You're Expecting". It scares people without giving much useful information.
Ina May Gaskin, Marsden Wagner, and Elizabeth Davis are a few good authors that come to mind.
In your case, it seems to me that the avalanche of problems started with the baby being posterior, which could have been fixed simply by you changing positions, or by the caregiver using his/her hands inside you and on your stomach to turn your baby. Instead, Pitocin, followed by breaking your water (getting the baby stuck), giving you an epidural (which made it harder, if not almost impossible, to make the baby turn) and a catheter, and then not answering when you called, all led to a very frightening and dangerous hemorrhage that could have been avoided in the first place!
Obviously, I'm very pro home birth, and I think you would be safe there, with a competent midwife, but where (and how, and with whom) to give birth is a personal decision that every mother has a right to make by herself.
If you would like, Dona International has a database of doulas that you can search to find one in your area.
I can try to help you find a good midwife in your area, if you want.
I wish you the very best of luck making these decisions.
Feel free to ask more, if you'd like.
I want you to know that I respect you for educating yourself.
Sheva
