Blood loss and Hemorrhage

Handout from Blood Loss Workshops

Estimating Blood Loss at Birth

Measurement Aids:

10 layers of double-ply paper towels will fill up and leak at appx 1/4 cup

1/4 cup soaks a hospital size sanitary pad

1/2 cup thoroughly saturates a hospital size pad, slightly more for an overnight type cloth diaper. (If the pad is full and dripping out when you pick it up, it contains at least 1/2 cup).

Blood mixed with water or amniotic fluid seems more than it is. Base your guess on the darker area in the center and ignore the lighter area on the sides. Remember that most babies have a cup or two of hind waters at birth and this may mix with blood and magnify the loss. Change to a clean, DRY, pad quickly in order to get a more accurate estimate.


SOURCES OF THIRD STAGE BLEEDING notes


Placental site

Tear or trauma; cervical, intra-vaginal, perineal

1. The placental site:

Partial – or complete -- placental separation occurs but uterus is unable to completely expel placenta. With placenta still inside, the uterus can not contract and close off the open blood vessels at the placental site.

EMPTY THE UTERUS!

Facilitate placental separation and expulsion:

  • Maternal effort

  • Controlled cord traction

  • Brant Andrews, manual expression etc

  • Oxytocics to aid contraction:

    • 10 Units Pitocin IM,

    • Misoprostol (cytotec) various dose recommended, 400, 600, 800; up to 1000 mcg. Oral and Rectal use are identical in time and effectiveness. For fastest oral use, mother should hold tablet in her cheek or under tongue. Cytotec is a new medication currently being studied for use in active third stage management. It’s unknown whether it should be advised “only” after placental delivery.


After the placenta is out, retained fragments or blood clots may prevent uterine contraction.

  • Expel clots through maternal position – sitting, or standing -- or maternal efforts such as coughing, sneezing

  • Expel clots by vigorous external massage

  • consider careful manual removal of clots


REMEMBER!

empty the bladder! A full bladder prevents contraction and increases bleeding.

replace fluids – shock mixture, IV, etc

monitor vitals

Bleeding may recur when Pitocin wears off in one to two hours! Be prepared.


Adherent Placenta

emergency transport for manual removal. Keep uterus contracted as much as possible to slow bleeding


Uterine Atony

The uterus fails to contract after placental delivery, allowing blood to continue flowing from open placental site. Uterus is soft, boggy


HELP THE UTERUS TO CONTRACT!

Oxytocic meds or herbs

Nipple stimulation (try to get baby to nurse)

Manually “rub up” contractions

Manually hold the uterus in state of contraction (bi manual, external or internal)

Manually put pressure on vessels (strong bimanual compression, aortic press)


Medicines

  • Methergine 0.2mg IM (if no hypertension). Many limit IM methergine use only to AFTER placental delivery.

  • Pitocin, cytotec/misoprostil, hemabate, or oral methergine (remember, only AFTER placenta is out)


Traditional treatments to release the placenta and/or contract the uterus

Herbal medicines; generally used as fresh tea or tincture.

  • Angelica: said to “release the placenta” by toning the uterus while it relaxes the cervix

  • Blue (Cohosh Caulophyllum): strengthens contractions

  • Shepherd's purse (Capsella bursa-pastoris) strengthens contractions, aids in blood clotting.

  • Trillium (birth root or beth root): strengthens contractions

  • Cotton Root Bark: strengthens contractions

  • (A combination tincture of the first three herbs is sold under the name “placenta out”. A combination called “Womb Strnge” contains the above herbs minus cotton root)


Herbs to slow bleeding or treat shock

  • Cayenne; powder taken in a little bit of water with sugar or honey, or as tincture. Traditional midwives often carried a small bottle of Tobasco (a vingegar tincture of cayenne peppers). Strengthens contractions; is said to regulate blood pressure and treat shock.

  • Yuunan Payao: Chinese herb compound to treat bleeding. Each bottle contains a capsule to be used for hemorrhage from any cause. Said to slow bleeding by increasing the clotting factors. Said to treat symptoms of shock. Use as treatment, not a preventive.


Other methods

  • An ICE PACK on the abdomen. Snug it down tightly over the uterus. The fundus will usually contract rapidly and strongly

  • ICE on the feet. This causes strong contraction through the sympathetic nervous system, and it also slows circulation and decreases bleeding

  • KEEP THE UTERUS CONTRACTED. If your hands get tired, you can use a weight such as a bag of rice or beans.

  • Elevate the foot of the bed. The pressure in the uterine sinuses is quite low. Raising the bed will slow blood loss.


Consider: Probably the single most effective treatment for hemorrhaged is produced within the woman’s own body: Her placenta! The placenta is a concentrated source of rapidly-absorbed oxytocic compounds. The chorion and body of the placenta contain large amounts of prostaglandins and other properties. Anthropologists tell us that placenta has been used as anti-hemorrhagic medicine in every human culture.

A small piece of the woman’s placenta can be placed under her tongue or held in her cheek. The mucus membranes will quickly absorb the necessary chemicals. The effect on the uterus is dramatic and very rapid: within three minutes you should feel a strong uterine contraction.

Placenta can also be given crushed or blended into a small amount of liquid. (Traditionally, this is tomato juice with a moderate quantity of Tabasco or cayenne, but any liquid will do).

The disadvantage of placenta medicine (aside from aversion) is that hemorrhage often occurs before the placenta is delivered. However, it’s appears that the membranes and cord also contain anti-hemmoragic properties. A piece of the cord would be readily available, and the membranes may be within reach.


Tear or trauma

Uterus is normally contracted, but bleeding still occurs

Cervical, vaginal, or rarely varicosities

Locate source and apply pressure with hands, fingers, kelly, or gauze pack. Maintain pressure for at least 5 minutes.

Suture or transport for control if needed

Traditional treatment: pressure with a gauze pad or cloth which has been soaked in vinegar

Yunnan Paiyao -- sprinkled on the wound. Or give capsule by mouth


copy write Gail Hart, Gist of Midwifery 1999, 2004