How Can Midwives Stop Hemorrhage?

How Can Midwives Stop Hemorrhage?

Midwives can stop hemorrhage by employing a multifaceted approach focused on early detection, prophylactic interventions, and rapid, evidence-based management protocols, ultimately aiming to minimize blood loss and safeguard maternal well-being. How Can Midwives Stop Hemorrhage? It’s about preparedness and swift action.

Understanding Postpartum Hemorrhage (PPH)

Postpartum hemorrhage (PPH), defined as excessive bleeding after childbirth, remains a leading cause of maternal morbidity and mortality worldwide. While PPH can occur unexpectedly, midwives are uniquely positioned to play a crucial role in prevention and management, thanks to their holistic approach, close relationships with birthing individuals, and expertise in physiological birth. Understanding the risk factors and potential causes is paramount.

Proactive Prevention Strategies

Prevention is the cornerstone of successful PPH management. Midwives are trained to identify and address risk factors antenatally and intrapartum.

• Antenatal Risk Assessment: This includes screening for anemia, bleeding disorders, multiple gestations, polyhydramnios, prior history of PPH, and uterine abnormalities. Addressing these issues before labor can significantly reduce the risk.

• Active Management of the Third Stage of Labor (AMTSL): This is the single most effective strategy for preventing PPH. AMTSL involves three key components:

  • Administering a uterotonic medication (typically oxytocin) immediately after birth.
  • Controlled cord traction (CCT) to deliver the placenta.
  • Uterine massage after placental expulsion.

• Promoting Physiological Labor: Encouraging upright positions, avoiding unnecessary interventions, and promoting a calm and supportive environment can optimize uterine contractility and minimize the risk of PPH.

Early Detection and Assessment

Even with preventative measures, PPH can still occur. Early detection is critical for timely intervention.

• Vigilant Observation: Midwives continuously monitor vital signs (blood pressure, pulse), uterine tone, and vaginal bleeding throughout the first few hours postpartum.

• Quantitative Blood Loss Estimation: Traditional visual estimation of blood loss is often inaccurate. Using calibrated collection bags or weighing blood-soaked materials provides a more objective assessment.

• Prompt Recognition of Warning Signs: Pale skin, dizziness, increased heart rate, and decreased blood pressure are all potential indicators of excessive blood loss and should prompt immediate action.

Immediate Management Techniques

When PPH is diagnosed, midwives must act quickly and decisively.

• Uterotonic Medications: Oxytocin remains the first-line uterotonic. If oxytocin is ineffective, other options include misoprostol, methylergonovine, and carboprost tromethamine (Hemabate). Contraindications and potential side effects of each medication must be carefully considered.

• Uterine Massage: Vigorous uterine massage stimulates uterine contraction and helps control bleeding.

• Bimanual Compression: Applying pressure to the uterus with one hand internally (through the vagina) and the other hand externally (on the abdomen) can compress the uterus and slow bleeding.

• Bladder Catheterization: A full bladder can interfere with uterine contraction. Catheterization ensures the bladder is empty, allowing the uterus to contract effectively.

• Fluid Resuscitation: Intravenous fluids (crystalloids) are administered to restore blood volume and maintain blood pressure.

• Assistance and Referral: If initial measures are unsuccessful, it’s crucial to call for assistance and prepare for transfer to a higher level of care. Collaboration is key.

Addressing the “4 Ts” of PPH

Understanding the underlying cause of PPH helps guide management. The “4 Ts” represent the common causes:

• Tone (Uterine Atony): The most common cause of PPH, where the uterus fails to contract adequately. Uterotonic medications and uterine massage are the primary interventions.

• Trauma: Lacerations, hematomas, or uterine rupture can cause significant bleeding. Careful examination and repair of any trauma are essential.

• Tissue (Retained Placental Tissue): Retained placental fragments can prevent the uterus from contracting properly. Manual removal of the placenta or curettage may be necessary.

• Thrombin (Coagulation Disorders): Underlying bleeding disorders can contribute to PPH. Blood tests and consultation with a hematologist may be required.

Documentation and Debriefing

• Meticulous documentation of all interventions, vital signs, and estimated blood loss is crucial for ongoing care and audit purposes.

• Debriefing after a PPH event allows the care team to review the management process, identify areas for improvement, and support the emotional well-being of all involved.

Common Mistakes and Pitfalls

• Delay in Recognition: Hesitation in acknowledging the possibility of PPH can delay critical interventions.

• Underestimation of Blood Loss: Relying on visual estimation alone can lead to underestimation of blood loss and delayed treatment.

• Failure to Initiate AMTSL: Omitting or incompletely performing AMTSL significantly increases the risk of PPH.

• Lack of Preparedness: Not having uterotonic medications and necessary equipment readily available can hinder timely management.

• Poor Communication: Ineffective communication among the care team can lead to confusion and delays in treatment.

Table: Uterotonic Medications for PPH

Medication	Dosage	Route	Contraindications	Considerations
Oxytocin	10-20 IU IM or IV infusion	IM or IV	Allergy	First-line uterotonic; generally well-tolerated
Misoprostol	600-800 mcg sublingually	Sublingual	Allergy	Can cause shivering and fever; effective but less potent than oxytocin
Methylergonovine	0.2 mg IM	IM	Hypertension, pre-eclampsia, cardiac disease	Can increase blood pressure; monitor closely
Carboprost	250 mcg IM (may repeat q15-90 min up to 8 doses)	IM	Asthma, glaucoma, cardiac disease	Can cause diarrhea, nausea, and vomiting; use with caution

Frequently Asked Questions (FAQs)

What is the most effective way to prevent postpartum hemorrhage?

The most effective method to prevent PPH is Active Management of the Third Stage of Labor (AMTSL), which involves the administration of a uterotonic medication, controlled cord traction, and uterine massage following placental delivery. This proactive approach significantly reduces the risk of excessive bleeding.

How soon after delivery should oxytocin be administered to prevent PPH?

Oxytocin should be administered immediately after the birth of the baby, preferably within one minute. This timing helps to stimulate uterine contractions promptly and prevent excessive bleeding.

What if oxytocin is not available?

If oxytocin is unavailable, misoprostol is a viable alternative. While less potent than oxytocin, misoprostol is effective in stimulating uterine contractions and can be administered sublingually.

What are the signs of uterine atony?

Signs of uterine atony include a soft or boggy uterus that is not contracting firmly, excessive vaginal bleeding, and potentially, signs of hypovolemic shock such as rapid heart rate and low blood pressure.

What should a midwife do if bimanual compression is not effective?

If bimanual compression is not effective, the midwife should continue uterine massage and administer uterotonic medications. It is also crucial to call for assistance from a physician or transfer the patient to a higher level of care facility immediately.

Is there any role for tranexamic acid (TXA) in PPH management?

Yes, tranexamic acid (TXA) can be a valuable adjunct in PPH management. TXA is an antifibrinolytic medication that helps to stabilize blood clots and reduce bleeding. It is most effective when administered early in the course of PPH.

How important is accurate blood loss estimation?

Accurate blood loss estimation is critical for guiding management decisions. Visual estimation is often inaccurate, so using calibrated collection devices or weighing blood-soaked materials provides a more objective and reliable assessment of blood loss.

What role does hydration play in PPH management?

Maintaining adequate hydration is essential for sustaining blood volume and blood pressure during PPH. Intravenous fluids, such as crystalloids, are administered to replenish lost fluids and support cardiovascular function.

How can midwives address cultural beliefs that might hinder PPH management?

Midwives can address cultural beliefs by building trust and rapport with the birthing person and their family, providing culturally sensitive education about PPH and its management, and respectfully incorporating beneficial cultural practices while ensuring evidence-based care.

What are the long-term consequences of PPH for the mother?

Long-term consequences of PPH can include anemia, postpartum depression, Sheehan’s syndrome (pituitary gland damage), and in rare cases, death. Prompt and effective management can minimize the risk of these complications.

How does delayed cord clamping affect the risk of PPH?

Delayed cord clamping may slightly increase the risk of PPH in some cases, particularly if the uterus is not contracting well. However, the benefits of delayed cord clamping for the newborn often outweigh this risk, and it can be safely practiced with close monitoring for PPH.

What is the midwife’s role in postpartum follow-up after a PPH event?

The midwife plays a crucial role in postpartum follow-up after a PPH event by monitoring for signs of anemia, infection, or other complications, providing emotional support and counseling, and ensuring appropriate referrals for ongoing care. They should also review the PPH event to identify areas for improvement in future practice.