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Preventing Postpartum Haemorrhage with Prenatal Care

Preventing Postpartum Haemorrhage with Prenatal Care-2

When I set out on the journey of planning our fourth baby, I knew I would be labelled 'high risk' by the medical profession due to previous postpartum haemorrhages (PPHs) during my second and third births. My first two births were in hospital. I was inducded for the first and, as a consequence, then experienced further interventions. My seond birth, 21 months later, was spontaneous and largely intervention-free, but with a managed third stage. I suffered a large PPH of 950ml (only noticed during a routine check a few hours after the birth, although I had probably been bleeding slowly since my baby was born) and, three hours after the birth, I was whisked off to surgery for a dilation and curettage on the assumption of retained placenta. I was already suffering from the blood loss and was very 'out of it' before corrective action was taken.

When planning my third birth with my midwife - this time after a nine-year gap - the issue of my last PPH came up. We assumed that it had been a result of my third stage being managed and, therefore, that there was a good chance another PPH would not occur. I also hoped my choice of a homebirth would reduce the possibility of negative outcomes.

I enjoyed a lovely pregnancy and birthed my baby in six hours. Once again I started to bleed slowly after birth, but this time my midwife monitored me closely and, with my consent administered a shot of syntometrine an hour after the birth. While this stopped the bleeding, my blood pressure remained abnormal due to the amount of blood already lost (more than a litre). I still felt very sick and not really 'with it', so we decided to transfer to hospital two hours after the birth. The hospital experience wasn' t fantastic, but the blood transfusion I consented to made me feel much better than I had after my second birth with no transfusion.

When I fell pregnant with my fourth baby, I considered the choice of midwives in my area and decided my best option was to remain with the midwife who had cared for me during my last homebirth. She advised that another homebirth was possible, but said she would prefer to manage the third stage from the start. This was not something I was keen to do - having experienced postnatal depression (PND) with my fi rst baby, I was aware of the importance of not interrupting the high natural oxytocin levels that are present in the first hours after birth.While I really resperted my midwife and was happy with how she handled the situation with my PPH, I did not want a managed third stage. I also had a feeling that I needed something different for this birth. Though I wasn't sure exactly what.

When I met with my midwife at five weeks, I explained my wishes for a natural third stage, explained that my confidence had grown in relation to child birth and said that, if it turned out my pregnancy was multiple or a breech presentation, then I might need to look for another midwife. She was happy with this, and we started out on the journey for my fourth baby.

As the weeks passed I became increasingly uneasy about my midwife and still felt I needed something different for this birth. Around 14 weeks into the pregnancy I felt very stressed and confused. Because it was a busy time of year, I hadn't yet had my official first appointment with my midwife. I contacted another midwife from Melbourne and discussed possible alternative midwives who might travel to support me in my birth. I learnt of one who lived an hour from us who might consider travelling to care for me. I phoned her the next day and immediately sensed a peace coming from her that felt 'right'. She agreed to meet me two weeks later to chat about my ideas.

From the start of this meeting we clicked. After two hours of debriefing my births, discussing my desires, her philosophies and how they all fitted together, I knew she was the right midwife for this pregnancy and birth.

By this time it was mid December and, because my new midwife was going away in January, we made our first appointment for the start of February when I would be 24 weeks. I felt good about this timeframe as I wanted fewer appointments during this pregnancy and, at this stage, wasn't ready to fully 'enter into' the pregnancy. I wasn't disconnected from it, but I was at peace with where I currently was and needed to remain there for a while.

When February came around I was ready and excited finally to be starting the journey. At our first appointment the PPHs were top of the agenda and we discussed what we could do to reduce my chances of another one. My midwife knew my wishes for a natural third stage and supported this, unless I bled quickly or the bleeding would not stop. I agreed that I would definitely want her to take any necessary steps to ensure my safety if I had a quick bleed (which was not in my history) or if my bleeding continued. We also discussed various alternatives to reduce the chance of bleeding, such as using certain herbs; breastfeeding sooner after birth (I did not feed my third baby until more than an hour after birth); creating a quiet, dim and uninterrupted birth space; and ensuring that I could quickly access the toilet to empty my bladder and get onto the bed to get comfortable after birth (all things that were missing from my third birth).

My midwife also suggested exploring possible emotional/psychological reasons for the bleeds as I progressed through the pregnancy. We continued our appointments every few weeks and, by 31 weeks, I was feeling very tired and unwell within myself. My midwife challenged me about my overall health and suggested I start to see an acupuncturist to work on my blood and energy levels and a chiropractor to work on my back, which had been sore for some time. I was also conscious of the fact that I had been diagnosed with pregnancy induced osteoporosis four months after the birth of my third baby, when I experienced two spinal fractures. This had caused me to lose 4 cm from my height. It dawned on me that I only had nine weeks until I was 'due' and that I needed to really step up and take control of my health, not see out the rest of my pregnancy feeling out of control and in pain.

At 32 weeks my midwife found the baby in a transverse position, which again motivated me to get on top of my health. I knew it was still early, and that transverse presentation at this time was quite normal in subsequent pregnancies, but the height I had lost since my last birth put some 'unknowns' around positioning and room for the baby to move. I saw an acupuncturist at 33 weeks and a chiropractor at 35 weeks. The acupuncturist advised that my blood was not looking good and she needed to work on balancing it out to reduce the chance of bleeding at the birth. She also noted the transverse position and did some work on encouraging the baby into a head down position. After my first visit my energy started to increase. I continued to see her fortnightly right up until the birth.

By the time I saw a chiropractor at 35 weeks, my baby had already turned head down. The chiropractor just worked on my pelvis, which she said was restricted by 3 cm. She was surprised I had not had any pelvis pain as yet, only back pain.She adjusted it gently and then made two follow-up appointments to take me up to the birth.When I returned to see her two weeks later, I was still without back pain and feeling great - my pelvis had stayed in the right position and there was no need for me to come back unless I had pain again.

The next week I finished work and was still feeling great. This was very different to my last pregnancy, when I took sick leave and finished six weeks earlier than planned because I was so tired and in so much pain. I felt confident about the changes that were happening with my health, and this gave me hope that this time we would be able to birth at home without a transfer and enjoy the time after birth, for the first time since the birth of my first child, 13 years before.

I started reading Shivam Rachana's Lotus Birth, which really spoke to me and helped me to start exploring the possible emotional/psychological aspects of my two PPHs. I thought about the depression I had experienced after the birth of my first child, which was still there after the birth of my second, and wondered whether my PPH was a way of trying to stop the pregnancy ending, so I didn't have to move onto the next step of being a mother. Even though it had been years since my PND, and I had done a lot of work to find healing from it, I acknowledged that my body could still be reacting in the same way. I also wondered whether I could feel the same way with my fourth baby. (Even though I did not experience any PND with my third baby, the back fractures I suffered when she was four months old resulted in chronic pain for a long time afterwards.) I wondered if choosing a lotus birth could be a way of slowing the birth, embracing the placenta and not feeling pushed onto the next stage so quickly.

I discussed this with my midwife at my next appointment and she agreed that it was a good idea. She was very familiar with lotus births, having supported many over the years. My husband was not as comfortable with the suggestion but, when I explained the reasons behind it, he soon agreed that it was my decision, as I felt so strongly about its place in our plan to reduce the chances of another PPH.

At 37 weeks I experienced a beautiful Blessing Way organised by a dear friend of mine. This time was very special, with candles lit, prayers expressed, births shared and my friends and family sent home with their own personal prayer request for my birth, which included a prayer asking for a normal birth with minimal bleeding.

At 39 weeks I went back to my acupuncturist who commented that I actually had 'too much' energy and she needed to balance me out the other way a bit more! I was getting up every morning at 8 am and going non-stop until 11 pm at night before I dropped into bed. This was unprecedented for me: I usually crashed in the last trimester, needing afternoon sleeps most days. That night I was quickly exhausted and, over the next few days, was very tired and needed to sleep in the afternoon again. This had me worried, so I emailed the acupuncturist to make another appointment for the following week. But my energy levels improved, so I decided to cancel the appointment.

By the Wednesday of the next week I finally felt 'ready' to have the baby. I knew I had done everything necessary in the prenatal period to fully prepare for the birth, and I was very confident that we had a great chance at not experiencing another PPH. Now it was time to wait until my baby was ready to come. It turned out we did not have to wait long.

On the Friday night I went into labour and our fourth baby was born early Saturday morning with only a 550 ml loss after birth. I am so thankful that I trusted my instincts and continued to look for another midwife, who really helped me to prepare physically, emotionally and even spiritually for a normal birth. I am also thankful for my beautiful husband who supported me at every turn, even when I didn't make much sense to him and he wasn't sure exactly why I needed a different midwife or a lotus birth. He now understands why and has expressed his admiration for my decisions. He is in awe of the way I birthed, finally doing it completely my way.

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