July 9, 2003
Volume 5, Issue 14
Midwifery Today E-News
“Postpartum Hemorrhage”
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In This Week's Issue:

Quote of the Week

"If a woman knows too little today, knowledge is replaced with fear and her chances for a normal birth are nil."

Jan Tritten

The Art of Midwifery

Pipe insulation is great for back labor—mom can lean against the pipe insulation while sitting up in a chair or on a bed. Some people use "fun noodles" from swimming pools. Pipe insulation is the same thing only it's not in fun colors and it costs much less. You can also use it in birthing pools—behind necks or in between mom's legs as well as behind her back. Buy a section of it and cut it is as you go. One of the last things I do before I leave the house for a birth is cut off a piece of pipe insulation!

Susan M.
Midwifery Today Forums

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

Send submissions, inquiries, and responses to newsletter items to: mtensubmit@midwiferytoday.com.

News Flashes

A study examined newborns for birth defects related to anticonvulsant drugs. Each newborn belonged to one of three groups: newborns exposed to anticonvulsant drugs in the womb; newborns of mothers with epilepsy who did not take anticonvulsant drugs; and newborns of mothers without epilepsy or a history of seizures. Results showed birth defects were more frequent in infants exposed to anticonvulsant drugs (20% of infants exposed to one drug had birth defects and 28% of infants exposed to two or more drugs had birth defects). However, the infants of mothers with epilepsy who were not treated with anticonvulsant drugs were at no greater risk of birth defects than infants of mothers without epilepsy.

New England Journal of Medicine



September 17–21, 2003 — Santa Monica, CA
CME/CEU: 34.25/41.3

California Family Health Council, EPA Division, 492 Division Street, Campbell, CA 95008
(408) 374-3720 ext. 222, wagnerg@cfhc.org, epa.cfhc.org/html/clinical_ed_.htm

Preventing Postpartum Hemorrhage

The first key to preventing postpartum hemorrhage is good prenatal nutrition and supplements. I always require that my mothers keep a five-day diet diary to give me early information about their diet. As soon as possible I recommend changes in their dietary habits if they are needed. I encourage them to use such supplements as liquid chlorophyll, red raspberry and nettles. I also make a tincture of nettles, yellow dock, alfalfa and red raspberry, which I have on hand if it is needed. I have found the Spectrum 2C multivitamins by NF Formulas to be unsurpassed in their effectiveness for pregnant and lactating women.

The second key, knowing the mom, entails making sure that you have recent blood work for this pregnancy. Check hemoglobin and hematocrit, of course, but also platelet count. You want to make sure the mother's blood will clot properly after the placenta detaches. This key also includes knowing the mother's nutritional status as discussed above.

The third key to preventing postpartum hemorrhage is to not rush the delivery of the placenta. Almost all postpartum hemorrhages, in my opinion, are caused by being in a hurry to deliver the placenta. In these cases, I believe hemorrhage is caused by the intervillous spaces not having a chance to contract and help control the flow of blood. Also, the overmanipulation of the uterus to facilitate placental delivery can 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. This is not any fun for the mother or the midwife! I have seen many physicians and a few midwives who will not give the placenta time to deliver on its own. I, too, have fallen victim to feeling a little harried as I waited for the placenta to come. But a policy of hands off, unless there is due cause, is the most important key to preventing postpartum hemorrhage. I have seen some bad postpartum bleeds, which may have been avoided if the practitioner had not intervened and over-managed the placenta delivery.

Uterine atony is also a major reason for postpartum hemorrhage. This 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. Try to anticipate this if she has had either of these labor patterns. Also, check and ascertain that she has not displaced her uterus by not emptying her bladder, either shortly before pushing and/or after delivery of the baby.

Excerpted from "Three Keys to Avoiding Postpartum Hemorrhage,"
by Margaret Scott, CM, Midwifery Today Issue 48

To read this article in its entirety, click here.

If there is bleeding that is not from lacerations and if the placenta is still inside, it must be delivered. The maternal vessels that nourished the pregnancy will not be able to contract and control the bleeding until the placenta is out of the way. These vessels have been wide open in the final weeks of pregnancy, with a pint of blood a minute coming through the placenta. The crisscross muscle fibers of the uterus, which have been called "living ligatures," tighten in around these vessels to close them off; the vessels themselves draw in and close down where they were severed with placental separation; and the blood coagulates, blocking further flow.

If the placenta is retained without bleeding, evaluate carefully before making attempts at delivery. Mark the top of the fundus and watch it to see if it is rising, suggesting concealed blood loss. If it is not rising and there are no signs of blood loss, the situation is stable. Partially separating a placenta that is abnormally adherent and then being unable to complete delivery means that a site for bleeding has been opened up. The bleeding is unlikely to stop until the placenta is completely delivered.

If hemorrhage occurs with the placenta out, direct pressure by external or internal bimanual compression of the uterus will stop the flow of blood while other measures are being taken to help the mother's system work. These may be fluid replacement, herbs or medicines, or simply getting the baby to nurse to encourage uterine contraction. It is best to use manual methods to prevent further loss while a second attendant gives Pitocin or shepherd's purse. Expressing clots may be necessary to stop the bleeding. They can mechanically prevent the uterus from contracting effectively, same as the retained placenta, causing continued blood loss.

Obstetrical definition states that loss of more than 500 milliliters of blood (close to one pint) during the first 24 hours after birth constitutes postpartum hemorrhage. And yet, studies that have used marked red blood cells to calculate the true blood loss in normal delivery have found that nearly half of women giving birth lose 500 milliliters or more.

Excerpted from "Hemorrhage During Pregnancy and Childbirth,"
by Marion Toepke McLean, Midwifery Today Issue 48

Learn more about hemorrhage. Order a copy of Midwifery Today Issue 48: click here.

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Forum Talk

Are you a lay or certified doula? To be certified, where did you go through training and what do you think about it? If you're a lay doula, do you think that a lack of certificate hinders your work? How long have you been doing this?



Question of the Week

Q: What can be done for endometrial hyperplasia as far as alternative methods of treatment? In my case, it falls under the category of excessive bleeding. Three cycles of progesterone haven't helped, and I don't really want to go the hysterectomy route.


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line.

Question of the Week Responses

Q: What can be done for a broken coccyx? I am six weeks postpartum and still cannot sit without pain. I had a vaginal delivery. I have to sit on a pillow with the back cut out and it still hurts.

— G.G.

A: I am an acupuncturist and Chinese herbalist. I have also had two severe coccyx injuries. In my experience, the pain of this injury goes away *very* slowly. Acupuncture can be very helpful. In my second injury, I took an herbal formula called "Trauma 2." Within an hour my coccyx felt much better, and I was back to normal within a few days. I took this formula in soup form, meaning I cooked up all the roots and barks and resins. It is available in pill form as well from Crane Herb Company (www.craneherb.com).

— S.W.

A: I do not have a solution, but would love to hear suggestions. I am 22 weeks pregnant and I broke my coccyx six years ago. I often have to pop it back into place, and the last few weeks it has become increasingly painful. If I sit or walk, it gets worse.


A: I have found that cranial sacral therapy works wonders for a broken coccyx. This is a very painful condition and will likely take longer than six weeks to get better. If the tailbone heals out of place, pain can continue for life or until it is broken again and reset.

I recommend seeing an osteopath first. Some women have good success with a chiropractor. Homeopathy can be very helpful as well (i.e., homeopathic comfrey, but it is best to have a classical homeopath assessment first).

Emotionally, issues with the tailbone (birth trauma) can be explored using hypnotherapy. Self suggestions for healing well, having all the support you need, giving the tailbone permission to drain out the pain, etc., might also help.

Shawn Gallagher, RM, C.CHt

A: I recommend sitz baths in comfrey leaf and/or root comfrey—one of the best healers and cell proliferators in the herbal world. Comfrey is also known as "knitbone" because it helps broken bones heal fast. It will also help soothe and heal the perineal tissues postpartum and is, therefore, one of the main ingredients of my postpartum sitz bath herb pack. Note: If infection is present, comfrey is not recommended because its healing abilities are so fast it may heal over the top of an infection and create a bigger problem. But if your vaginal/perineal area is infection free, it would be the way to go to heal that bone as fast as possible and get you on the road to recovery and feeling better!

— Pam Caldwell,
herbalist specializing in pregnancy, birth and postpartum

A: Homeopathic Hypericum and Arnica. Dose: Take 3 pellets 30C once a day for 3 days of each remedy. Pay attention to your body's reaction—does it get worse, better, no change? If it gets better then pain returns once done taking remedy, take another dose, etc. You always want to take the minimum dose.

No relief from either of these remedies—try homeopathic Silica 30C for 3 days; it has an affinity for pain in the coccyx.

No relief still? Find a nice affordable homeopath to "take the case." They have great results with things of this nature.

— Cheryl

A: First and foremost, are you sure your coccyx is broken? Have you had it X-rayed? My suggestion for you is to see a chiropractor. Some misalignments of the pelvis and sacrum may manifest as coccygeal pain. During childbirth, these bones move in order to accommodate the child, and it is possible that now they are stuck in a malposition.

— Ann Krzyzelewski, DC

A: I too broke my coccyx but not when I had a child to take care of. Unfortunately, there is nothing you can take for the pain. You have to stay off your feet as much as possible—I know, it's nearly impossible with a baby—but time is what heals it.

The best advice is to leave the things that don't matter such as cleaning the house, doing laundry, running unimportant errands, food shopping. Hopefully, you have someone who can help you with those things so you can focus on just caring for you and baby.

— Anon.

A: I too fractured my tailbone during birth. It has been four months postpartum and it will heal if I take it easy, then if I sit in a hard chair or in my car, it hurts again.

— Sarah

Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mgeditor@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

Exclusively on the BirthLove site: Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out! www.birthlove.com/glo_doula.html


I'm responding to the writer who felt that all fathers should be present at the birth, citing the fact that her husband was lovingly involved in the creation of each child [Issues 5: 10 and 11]. Unfortunately, that isn't always the case. In my practice, there are many unhealthy mother-father relationships, even uncertain paternity. Some of the fathers have been physically abusive toward the pregnant mom. Some of these women relax and labor more easily without the father present. Others desperately want him present, no matter how he has treated her. I respect a woman's right to choose her companions for birth, although sometimes I have to grit my teeth when I know some of the history and have seen the bruises. I've even had mothers want me to call a judge and ask for the father's release from jail, when he is in jail for assaulting her! How do other midwives and care providers deal with these situations? I worry that my bad vibes will affect her, even though I try to contain my feelings.

Rose Evans, CNM
Anderson, Indiana

I am a long-time reader of Midwifery Today and am a Bradley childbirth instructor. I just gave birth to my third child one week ago and had a most unusual experience in my third trimester. I continued to nurse my 1-1/2 year old during my pregnancy even though my milk supply virtually disappeared early in the pregnancy. At 30 weeks, my milk returned in very small quantities, and with it came intense nipple pain. I would have "attacks" that would come many times a day. My nipples would blanch white, then turn bluish purple, then rosy red. These color changes would accompany varying types of pain from sharp, stabbing pain to a dull throbbing ache. I was frequently left in tears. My midwife suggested I might have Raynaud's disease, but affecting the nipples instead of the fingers or toes as it commonly does. I did extensive research on the Internet and found it to be very rare but not unheard of. All of the cases I found related to women having the problem during breastfeeding, not pregnancy (which makes sense because not a lot of women experience lactation during pregnancy—I did only because of my nursing toddler).

My family practice doctor recommended weaning my son, but I couldn't bring myself to do it. So I suffered through 10 weeks of this because I would not take the only cure I could find for it, which is a low dose of Nifedipine (a hypertension drug). I was prepared to start the medication as soon as I delivered because the La Leche League site said it was safe for nursing moms. I was terrified of having this pain while nursing a newborn every hour! But as miracles go, this problem resolved itself quite unexpectedly. The morning I went into labor my pain disappeared. The cessation of pain actually preceded the labor. I haven't had a single flash of pain in more than a week, and nursing is going very well. I have no clue as to why my body "fixed" itself and this problem disappeared as fast as it came, but I wanted to pass my experience to other midwives who might find themselves faced with clients in this challenging situation.

— Samantha Ste.Claire
Daytona Beach, Florida

I am the mother of a child of six months and want to breastfeed my child. What suggestion would you give to increase milk flow? Is it true that mothers with white breasts like me and areolas of light colour produce low milk? Does breast size also affect milk production?


Regarding prolonged latency [Issue 5:13]: You were doing everything right until you had your waters broken at 7 cm and then stalled again. I have had several women have sessions of labor, even dilating to 7 cm, and then stopping again for a while. If you had left it alone at that stage, your last session of labor would probably have been very short, almost a precipitous delivery. Raspberry leaf tea and extra calcium (calcium citrate or calcium lactate) may also have helped. Next time it could be very similar irregular labor or more conventional. Each baby is different. Your body knows exactly what you and your baby need in each situation. Trust it instead of interfering and trying to force it. The hemorrhaging afterward could have been the result of other things—was the placenta pulled out immediately, were you allowed to nurse the baby immediately, what kind of nutrition were you allowed during the hospital part of your labor? At home there would have been less interference in your labor by most midwives, although there are some who follow more medical protocol and would have broken your waters also.

Judy, CPM

I saw an interesting question in one of your old issues regarding treating pinworms in pregnancy. One of the midwives recommended pumpkin seeds. Is pumpkin seed oil good? How much and for how long? Are toasted pumpkin seeds OK or does toasting destroy the antiworm properties? Can I use it in very early pregnancy? And how often should I wash the sheets and nightclothes once I start treatment? Every day for two weeks?


Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


Michigan School of Traditional Midwifery 6th annual Midwifery Skills Workshop August 17–20, 2003. Early registration discount extended through June 1, 2003—$335.00, $395 thereafter. Registration includes lodging, meals, workshop materials. For more information visit www.traditionalmidwife.com or call 989-736-6583.

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