risk of PPH with VBAC

[mumofesme]

I gave birth via emer c/sec 14 months ago. Both my daughter and I are healthy and happy! But it was a very traumatic birth experience for me and there were a lot of things that went "wrong". Also, to make it even harder for me to deal with, I didn't properly understand [U]why[U] I had a c/sec. I blamed myself and the hospital and I was pretty upset and angry about the whole thing. But finally (I can't believe it took me so long!) I got in touch with one of the obs at the hospital to explain my birth to me and what and why everything happened. I'm going back to talk more but ultimately it was a very positive step in my healing.

HOWEVER, the reason for this long-winded post is that we briefly discussed my future births and I was hoping that some of you lovely ladies could give me some info.

He said:
If I choose to have lots more kids VBACs are the safest option (I'm assuming because of c/sec scar tissue) BUT if I only want one more kid a 2nd C/sec is my safest option. He gave me the deal about UR but in my case there is also a blood issue. I lost 1.5L of blood in post partum heamorraghe (how on earth do you spell that!). He said this PPH was due to a long labour (24 hours before c/sec). I won't accept blood transfusions so the doctor said that a c/sec would be safer for future births because of this stance.

Obviously I don't want to put my life or my future child's life in danger so I wish to take the safer option but I was under the impression that a VBAC is safer in terms of risk of PPH. Does anyone have more info about blood loss in VBAC?

[becca74]

the PPH sounds like it was a result of the c/sec....and you are more likely to have PPH if you have another c/sec, to be honest. That is the first time I have ever heard that a VBAC is more likely to result in a PPH. All the research I have gone through points to a C/sec being the culprit for PPH, more often than VB. I lost 800mls with my 2nd c/sec, and none whatsoever with my homebirth last year.

I have a friend who heomarages (sp? :laughing: ) after c/sec and vb, but her condition is extremely rare. Her's is to do with being over-exhausted and her uterus not clamping down afterwards. Her condition even has one of those long-winded latin names, it is so rare. If your PPH was a result of that, then your OB would have shared that long-winded latin name with you.....

Because a c/sec is unnatural, then your uterus is more likely to be confused about clamping down post partum, hence the greater risk for a PPH. With a VB, if you keep things as drug free as possible, the body is less confused, and follows through the birth process in the right sequence.

Things to prevent PPH are to put the baby to your breast ASAP (ie, immediately) after they are out, as this is the next procedure in the birth process. This action causes you to produce oxytocin, which causes your uterus to clamp down. If you have been healthy and well-rested before labour, this should all happen in a pretty straightforward way.


There are loads of resources you can look at, if you check previous threads, you will see some great links. start with these:

www.birthrites.org (http://www.birthrites.org)
http://www.plus-size-pregnancy.org/CSANDVBAC/csvbacindex.html
http://www.canaustralia.net/
http://www.cares-sa.org.au/
http://www.ican-online.org/

[Happy mum]

Hi

I had a successful vbac 6 weeks ago with the birth of my beautiful daughter, and I had no problems at all during the birth. The birth was just under five hours from when my waters broke to when she was born and I did it totally drug free. I did however lose a fair amount of blood during the birth and directly after the birth (just over half a litre), and then I had a PPH of about 1 litre a few hours later. I dont think this had anything to do with the vbac and the obs and midwifes at the hosp all agreed that it was not to do with the vbac and couldnt explain why it happened. I has breastfeed my daughter all afternoon after the birth and done all the normal things to start my uterus to clamp down but still unded up with a PPH. It really was not much to worry about for me because they gave me two needles in the leg of oxytocin (SP?) to help contract my uterus why they got the drip of oxytocin organised. All that had to happen was I had to remain in bed all night with the oxytocin drip in my hand and had to have a cathater inserted to keep my bladder empty as a full bladder puts added pressure on the uterus and increases the bleeding. This was only overnight and I did not see it as much of an issue as it could have happened at a normal VB or csec not just because it was VBAC. I did not have any PPH with my first baby (elective csec for breech presentation) and I dont see why there should really be any increased risks if it is a normal trouble free delivery. Your best option is to research it as much as you can and really talk it over with your obs and do what you feel is the best thing for you and your baby. Check back through the vbac threads for all sorts of info on VBAC because the ladies on here are worth their weight in gold for the knowledge and info they provided me in the lead up to my VBAC. Good luck xx

[Shanaynay]

Hi, just a quickie as I don't ahve time at the moment, I will come back - but I loss more blood with my emergency csec (about 1.5L) than I did with my VBAC (about 1L) :thumbsup:

[becca74]

There might be an association with a full bladder and PPH, as Happy mum mentioned....

at my SIL's birth, i remember the Middie insisting she go pee, and she was reluctant, and the MW became quite persistant; and after my 2 vag births, they were extremely keen for me to empty my bladder (I remember vividly my IMW, last year, making me get up to wee, she was very insistent).....I wonder if this was because they are worried about the uterus not contracting down properly?

Will have to do some :detective: work.....

[becca74]

okie dokie, I've just done a bit of homework, and found some info....hope it is helpful: (i've added italics/underlining).

From: http://www.midwiferytoday.com/enews/enews0135.asp



4) Avoiding Postpartum Hemorrhage

The three main keys to avoiding postpartum hemorrhage are good nutrition and supplements as needed, knowing the mother, and not rushing the delivery of the placenta. I always require that mothers keep a five-day diet diary. As soon as possible I recommend changes in their dietary habits if they are needed. I encourage the use of liquid chlorophyll, red raspberry and nettles. I also make a tincture of nettles, yellowdock, alfalfa and red raspberry, which I have on hand if it is needed.
The second key, knowing the mom, means making sure I have recent blood work for this pregnancy. I check hemoglobin and hematocrit and platelet count. I want to know if the mother's blood will clot properly after the placenta detaches.

As to not rushing the placenta, almost all postpartum hemorrhages are caused by being in a hurry to delivery the placenta. I believe hemorrhage is caused by the intervillous spaces not having a chance to contract and help control the flow of blood. Overmanipulation of the uterus can also cause lobes to be left on the uterine wall which result in uneven contraction of the uterus. These lobes need to be manually removed to prevent postpartum hemorrhage and infection.

Uterine atony is also a major reason for postpartum hemorrhage. It can be caused from a long labor or a precipitous labor, either of which can induce uterine fatigue and facilitate possible partial separation of the placenta. I also ascertain whether the mom has not displaced her uterus by not emptying her bladder, either shortly before pushing an/or after delivery of the baby.

-Margaret Scott, CPM in Midwifery Today Issue 49
====

5) Management of Postpartum Hemorrhage
Uterine atony causes about 70 percent of PPHs. This condition is usually very responsive to non-pharmacologic measures, and these may be tried first. I generally start with fundal massage and nipple stimulation, uterine re-positioning, then abdominal aortic compression, and finally bimanual compression. I consider whether the woman has emptied her bladder recently and is otherwise comfortable. If the uterus remains soft but bleeding is being controlled, herbal therapies like blue cohosh or motherwort may be considered, reserving oxytocic drugs for circumstances where a more definitive, heavy-handed approach is indicated. (Of course situations vary, requiring an individualized, dynamic response. For example, torrential hemorrhages I have managed responded well to immediate aortic compression followed by other interventions, which did not usually include pharmaceuticals.) Administration of oxygen at 4-5 liters/min. should begin with any signs of shock and/or blood pressure at or below 70/50. Emergency response measures should be initiated; steps taken to assure fluid resuscitation; and core-perfusion maintained via lower extremity elevation, and in some cases, anti-shock compression pants or wrap.
Should pharmaceutical oxytocics be indicated, the American Academy of Family Physicians recommends the following protocol: up to 40 units of oxytocin (Pitocin) in a liter of normal saline, administered at a rate of 250/mlhour, or 10-20 units IM. Oxytocin acts to rhythmically contract the upper uterine segment. (Direct, undiluted IV injection of oxytocin is to be avoided, as it increases hypotension, exacerbating perfusion problems associated with hemorrhage.) If the response to oxytocin is inadequate after several minutes and the woman is not hypertensive or toxemic, give ergonovine (Methergine) 0.2 mg IM. This agent acts on both upper and lower uterine segments, causing tetanic contraction and vasoconstriction. Note that ergot administration commonly causes transient hypertension, nausea or vomiting, dizziness, headache, palpitations, chest pain, or shortness of breath. Since many of these side effects are synonymous with symptoms of shock, special care should be taken to determine if adequate treatment response is occurring. Onset of action is two to five minutes.

Some practices have access to Prostaglandin F2 15-methyl (Hemabate), which may be administered IM or intramyometrially (injected directly into the uterus through the abdominal wall). Dosage is 0.25 to 1.0 mg, repeated up to a total of 2 mg. Onset of action is five minutes.
All the while the practitioner should be actively assessing the root cause of the bleeding, whether the treatments are working, and planning for the next step.

-Judy Edmunds, CPM, in Midwifery Today Issue 48



and



Q: What steps do you take in your practice to avoid postpartum hemorrhage (PPH)?

Don't cause it! (hands off during third stage). Get baby to breast soon. Have mom push out the placenta, no pulling.
This may sound silly but I often "talk to" the placenta, thanking "Madame Placenta" for its wonderful function and now, would you please come out? I think this calms me down (if it's a long third stage) and it calms the family and adds a little humor to an otherwise tense situation.

If the woman has a history of PPH, I will often offer her shepherd's purse tincture prophylactically, two droppers full under the tongue after the placenta delivers. Have her hold it under the tongue as long as she can stand it, then follow with a little bit of water to drink.

Massage the uterus and be very aggressive if you have to. Having worked over ten years in a hospital practice prior to doing home/birth center births, I learned to be very aggressive in this. I just put it down as a life saving measure and don't sweat not being nice.
Be aggressive with Pitocin followed by Methergine if the above doesn't help. The above measures have really worked well for me, and I very very rarely have PPHs.

-Annette Manant, CNM harmonyu@telisphere.com

====

As long as there is no (or very slight) bleeding, I wait for signs of placental separation. Sometimes if I need to stitch I go ahead with this, or just sit and admire the baby When the placenta has separated, I put a hand on the fundus to clue the mother in to when she has a contraction, and get her to push the placenta out. I do not find the test of placental separation where you push up the uterus and see whether or not the cord pulls up to be accurate. What this tells you is whether or not the placenta is through the cervix. If the placenta is separated but not through the cervix, I may assist the mother's pushes with controlled cord traction in the curve of carus.
I am more active if there is a lot of bleeding. After the placenta is delivered I make sure there are no clots in the uterus, then try to promote quiet time with privacy for mother and baby to tune into each other and get the baby onto the breast. The human body has natural mechanisms to stop the normal bleeding which goes along with childbirth before it becomes a hemorrhage, and I try to work along with these natural systems. However, I don't hesitate to use other, more interventive techniques if hemorrhaging begins. Too much blood can be lost very quickly.

-Marion Toepke McLean, CNM

[lilpearl]

Caesareans lead to a far greater chance of PPH than vaginal birth (inc VBAC). Bleeding problems in general are far more prevelent in women who have undergone the mojor surgery of caesarean section. I'd get the opinion of good midwives before asking an obstetrician questions about normal birth - they tend to not have the knowledge that midwives do (that is, real midwives, not the "we go by policy and what obs tell us to do" med-wives!