This is a tough subject. Bleeding or more specifically postpartum haemorrhage, is a common fear women have as they get closer to the birth of their baby.

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Does everyone bleed at birth? Well, yes everybody has blood loss during childbirth but normal blood loss is not what everyone is worried about. It is the post partum haemorrhage. The Lights and Sirens emergency.

In this podcast we cover:

• What is considered a post partum haemorrhage. (PPH)
• How blood loss gets measured
• Who is at more risk of PPH
• What causes PPH
• What happens if you have a PPH
• Will you have another PPH in subsequent pregnancies

+MOREROW

Brigid [00:00:36] Welcome, everyone, to Episode 25. How are you going Pat? 

Patrick [00:00:40] Look, I’m really well, we’re in the same session recording the previous episode and I’m just giving a puppy update. Gone to sleep. 

Brigid [00:00:49] I’ve gone to sleep yet, thankfully, because I think he started to chew on the cables. 

Brigid [00:00:56] All right. 

Brigid [00:00:56] So I want to start this episode, Pat, by reading a an amazing review that we had on our i-Tunes podcast. And it’s from Daphne. Thank you, Daphne. She’s got this is a long review. Sorry. Thank you for the work you do. Putting out credible, well explained evidence based information. Well, I’m currently 26 weeks pregnant and have enjoyed listening throughout my pregnancy so far. There is so much fear mongering out there in the pregnancy community and irrational fear of the medical system. A great deal of this mistrust of the medical system could be avoided if people listen to this resource. I’m a health professional myself, so I understand that I’m coming from a better position of understanding how the medical system works and is motivated. But I still find it baffling the total lack of respect and trust out there for obstetricians in hospitals. What gets missed is the sound clinical reasoning process behind all interventions associated with pregnancy and labour. Informed consent and joint decision making is so crucial and women should have the right to informed decision making about their and their baby’s care. But I find the privilege nature of our society at the moment. Sad as uneducated opinions garner more respect than that of someone with 10 plus years training and experience who has no other motivation than to help women and babies through a safe and healthy pregnancy and birth experience. I’d find this whole process quite overwhelming if it weren’t for my background. So it’s easy to see how someone with no health or medical understanding could be easily misled. Thank you again for the easy to understand and outstanding information. So I read that and I and you know, I was just thrilled that somebody would take the time to give us that sort of feedback. And it would, I don’t know where she’s typing it on a phone with her thumb working on it but that would have taken quite some time, all of that, right? Yeah. But it also made me feel a bit sad. 

Patrick [00:02:47] Look, it is sad if there is mistrust out there of expertise, you know, medical expertise in pregnancy space, because, you know, there is a sound reason behind behind induction. And I think a lot behind interventions like like induction, for example. And I think a lot of the misunderstanding comes when things are poorly explained. As simple as that. Yes. So a number of times throughout my career, if I’ve had somebody who was somewhat resistant to what I thought was sound advice, a misunderstanding as to why I was giving that advice was behind the problem a lot of the time. 

Brigid [00:03:24] Yes. And we do hear that, you know, we hear about bedside manner and, you know, some medical people not communicating effectively. a). I think a lot of medical people are really busy. And we end if we think about the social media space, seriously as not many medical people in the social media space, actually, there’s not even many obstructions or gynaecologists on the podcasting space. If you look at all the pregnancy podcasts, they’re often led or given by sort of non medical people. Yeah. 

Patrick [00:03:52] Yeah. So, you know, I think I hope that’s something that that that we’re offering is that that perspective in a digestible format like this. 

Brigid [00:04:01] Yeah. And I think sometimes where that mistrust comes from, say, for example, when you’re on call for the public hospital and I know someone’s having a baby that week, and I said, oh, you might say, Pat. And then I go, actually, he’s he’s the consultant on call. So if you see him, I hope you don’t say that’s not good for calling me if they’re calling you in. That means that that woman does need intervention. And I think sometimes the obstetrician coming in at that stage, sometimes that’s where the blame. 

Brigid [00:04:29] You know, they made me do it or, you know, that’s where they see that their progression sort of abruptly changed from, you know, this there’s no intervention birth, to something that was full of intervention that more might be something in there. Yeah. 

Brigid [00:04:45] Anyway, you know, I just wanted to sort of talk about that a little bit and say I hope that this information gets out there. If you know of people that need this information, then please share. So, yeah, I think it needs leads really nicely into our topic today. Pat, which we haven’t sort of announced, which is postpartum haemorrhage or bleeding at birth. 

Patrick [00:05:07] And so blood loss at birth. It’s pretty normal, isn’t it? Some blood loss

Patrick [00:05:12] Everyone’s going to bleed a bit. Yeah. In our occasionally it’s a very, very small volumes, but everyone’s gonna bleed a bit. Yeah. Normal births, caesarean section. There’ll be there’ll be some bleeding. Yeah. And so how much is normal. Well we we sort of talk more about how much is not normal. So the you know in our insert in in the hospitals that I work at the cut-offs of 500 mils. As opposed to having postpartum haemorrhage and that then that’s a it would code is a postpartum haemorrhage for data collection and so forth. So most people might have 501 million be fine. Yes. And and someone else might have 499 and feel that. Yeah. But certainly you can lose in the low hundreds and feel totally fine. Yeah. It’s one of the reasons why in late pregnancy we want people to have blood to spare. Right. Okay. Tons of tons of iron. Nice high haemoglobin when it’s checked at thirty six weeks so that they can come in with a bit to spare. 

Brigid [00:06:09] Okay. Yeah. Because if somebody had a low haemoglobin and had like a relative, say 400, would they feel that impact. 

Patrick [00:06:16] You will if you start at 100. Yeah. 

Brigid [00:06:19] 100 haemoglobin. Yeah. Yeah. 

Patrick [00:06:21] So start with you. Haemoglobin at 100 or 10 in the other system, there’s two systems. They numb and you lose 20 points. You might you might feel it at 80. Yeah. But if you came in at 120 and lost the same 20 points, you’d be a hundred and feel fine. 

Brigid [00:06:37] Yeah. All right. 

Brigid [00:06:39] So after I’d given birth to the boys, it really felt like a bit of a military operation. You know, that people were sort of saying, oh, how much blood, oh 400mls rada rada, you know, and they’ve got pads there. And and it all felt kind of like I didn’t know whether that was normal or not. And it felt a bit subjective. How did they actually measure how much blood you’ve lost? 

Patrick [00:07:00] Well, that’s a good question, because we don’t we don’t know that we’re always terribly good at that. What we’re going to you know, one of the things that we look at is, is just how much blood is on the towels, sheets, pads, packs. But it is a bit subjective. Yeah. But for example, if you’ve got linen with a known weight and then you weigh it, then anything, anything in in excess of the known weight of the linen is blood. Right. Okay. And one of the problems is that sometimes the haemorrhage might happen straight after the baby comes out. A whole lot of water comes out with the baby as well. Yeah, well, that might look like there’s more blood than there really is. 

Brigid [00:07:39] Yeah. Right. So you get a false positive for a postpartum haemorrhage yeah. Yeah, yeah. Yeah. 

Patrick [00:07:43] Most of the people with a significant postpartum haemorrhage are having multiple measures of the haemoglobin done after the birth. Yeah. So we can assess severity as well. Yeah. By things like hypotension, the blood pressure’s too low, tachycardia heart rate’s too high or the blood test says that the haemaglobin is too low. 

Brigid [00:08:01] Yeah. Well so can you can you describe a typical situation. What what is what happens when somebody has a postpartum haemorrhage? 

Patrick [00:08:11] Well, there are a number of causes, but the most common one is that the baby comes out and the placenta comes out and the uterus is relaxed and floppy instead of firm and well contracted. And they’re relaxed and and floppy uterus will bleed too much. Yeah. And the woman will bleed vaginally. And we need to intervene with a number of measures to get that uterus clamped back up again. Nice and tight. There are blood vessels running through the wall of the uterus, which is how the oxygen and nutrients get from the mother to the baby. And when the placenta comes off, those blood vessels are just sitting there open and will bleed unless the uterus contracts properly and squeezes the blood vessels shut. 

Brigid [00:08:56] And is that the same situation as a cesarean. Yes. Caesarean section, will. Well, you can get that. Yeah, but she can also get all sorts of other reasons to bleed, like surgical bleeding, like cattle. You know, you have to cut through a vein to get to the baby. Yeah, right. Yeah. So that’s one of the reasons why you can have a haemorrhage even even if their birth is by caesarean section. You’re right. And then there’s a couple of other causes for postpartum haemorrhage. That one’s called atonic bleeding where the uterus is too tired and it won’t clamp down properly. 

Brigid [00:09:25] Can I just stop on that? So why would the uterus be tired. 

Patrick [00:09:28] Or sometimes it just happens or sometimes there’s risk factors like labor’s too low. Yeah, that’s that’s a common one. So Labor’s gone very long. And just like the muscles in your legs at the end of a marathon, the the uterus is too tired. Won’t contract very well. Yeah. Or the uterus might struggle to contract because it’s been overstretched during the pregnancy by a very big baby or extra water or twins. Yeah. And so the uterus is really stretched out and it finds it hard to contract down. Yeah, right. And then there are other causes of bleeding like tears in the vagina that the baby’s head’s made on the way. Yeah. Or other rarer things where the bleeding might be happening because the woman’s blood clotting system has failed. 

Brigid [00:10:16] Yeah. And a woman that has a clotting problem, she’d probably know about that, wouldn’t she? 

Patrick [00:10:21] Yes. No. We know that there are a small number of people with a known clotting problem and we do know about them and we can prepare for that. But sometimes the clotting problem arises as the result of a of a pregnancy complications like preeclampsia, one of the features of severe preeclampsia is clotting failure. Or it might be that the clotting failure happens because too much blood has already been lost. So you have an ordinary atonic pph, the uterus too tired. And when you get a two or three litres down, suddenly the blood that’s left in the woman’s body when clot properly, then it all gets much worse. 

Brigid [00:10:58] This sounds really frightening. Is it frightening? 

Patrick [00:11:01] Yep, it sure is. So. So it’s still a thing. It’s a huge thing in the developing world where a lot of women who might be at high risk or even a standard normal risk are having babies away from the sort of expertise that’s needed to fix this. And, you know, the horrifying figures that we read about maternal mortality rates in the developing world, a lot of those are from haemorrhage. All right. But even in Victoria, in 2020, of the very small number of women who don’t survive pregnancy and childbirth, some of those deaths will be from haemorrhage. So it’s a real thing. Thankfully, it’s very rare. And the reason it’s rare in a developed country like ours is that we prevent it. We don’t sit around waiting for the haemorrhage to happen. Yeah. Yeah. And the prevention of haemorrhage has been the major obstetric intervention in the 20th century. That’s actually made a huge difference to maternal survival. 

Brigid [00:12:05] We’ll talk about that in a minute. I just want to ask. Because I’m still back on like I’m frightened by this. And it was something in my pregnancies that I was fearful of because I think, once again, you know, that’s what gets portrayed on some of the old movies that you might watch. And yeah, it’s it’s just a fear that I did have during my pregnancy. 

Patrick [00:12:24] Yeah, I get that. It’s I get that scary, I think. I think to be honest, it’s something that a pregnant woman should know exists. Yes. Ideally, would know a little bit about, you know, from listening to something like this and then and then be aware of the strategies that we use to prevent it. And some of the things we might do to treat it if it happened despite the preventative stuff. 

Brigid [00:12:47] And I actually think this might be good listening for the partner, because I could imagine for the partner, like if you see your partner having the baby and they have a postpartum haemorrhage or whatever, and then, you know, you might get shunted out of the room on your partner shooshed up to theatre, or whatever it might be. And I think that would be very traumatic. 

Patrick [00:13:06] It really is horrible. Yeah. Yeah. So what if we if we get to the point, you know, postpartum haemorrhage, where we need to take a woman to the operating theatre to start doing surgical things, to stop the bleeding. Poor old partner’s there with the baby. Yeah. Back down on back down on the labour ward. Nightmare. Nightmare situation. 

Brigid [00:13:25] Everyone who’s listening, just take a big, big breath. Breath in. Breathe out. All right. 

Patrick [00:13:31] Pretty uncommon. Yeah, pretty uncommon. How common is that? Potentially serious, but we’re really great at fixing it and preventing it. OK. 

Brigid [00:13:38] Do we know how common it is? 

Patrick [00:13:40] Yep. It’s at least 10 per cent of people would meet the criteria for postpartum haemorrhage, but very few of those people would become critically unwell. Right. Does that make sense? I mean, most of them are things that we manage quickly and easily, but they’re still meeting. They’re still getting 500 mls. Yeah. And, you know, one of the risk factors for postpartum haemorrhage is, is advancing maternal age and obesity. Yes. And there are things that we deal with these days much more often than they used to. 

Brigid [00:14:14] So you’ve talked about a big baby. So when we say big baby, what are we talking? 

Patrick [00:14:18] All the major risk factor is a real is a macrosomic baby so like four kilos or above where where we start to think, rightio, how can we we don’t we don’t want to be on the labour ward waiting for a four kilo baby to come out, followed by a massive postpartum haemorrhage. We how can we. How can we be ready for this? So we know from ultrasounds and measuring woman’s tummy that she’s got a really big baby on board. So we say fine. On that day on the Labour ward, we’re hoping that she dilates up nicely and push the baby out vaginally. But what might we do differently? What we might put an I.V. line in the back of the woman’s hand so that if we needed to give her drugs, we could do it straight away? Yes. Without needing to muck around getting that I.V. line in in an emergency. Yeah. 

Patrick [00:15:02] We might send a few mls of her blood off to the blood bank at the start of the day saying four kilo baby, high risk postpartum haemorrhage and get those guys to crossmatch her blood. Yeah. So that so that if she has a really big haemorrhage and needs a blood transfusion, it’s good to go. 

Brigid [00:15:18] It’s all there. Ready to go. All right. We’ll get on to treatment. But now, can we talk about prevention? Well, what do you do to prevent a PPH? 

Patrick [00:15:26] Well, there’s a number of things. One is trying to trying to predict who’s going to have one. Yes. So that is actually kind of possible. You can certainly identify people who might be sitting ducks and do special things to mean that if one happens, we’re good to go. Yeah, managing it. We. We drill for it. So if there’s ever a quiet day on labour ward. Yeah. Then we do drills. Yeah. 

Patrick [00:15:53] I can sit around with the junior people and say right here Mrs. Boggs is here and she’s just had a haemorrhage waiting into. Yeah. Not that, not that I change my trousers. And then we have other preventative strategies like the little injection that you haven’t your thigh once the baby’s out. 

Brigid [00:16:13] What’s that again. Clexane? 

Patrick [00:16:15] No. Clexane is the clot preventer that we gave for people who are at high risk of deep venous thrombosis. So this is drugs like syntocinon and ergometrine, which are drugs that make the uterus contract. Right. And if everyone has little injection of that in the thigh when the baby comes out and then it dramatically reduces the risk of haemorrhage. 

Brigid [00:16:37] And you have that before the placenta comes out. Yeah, yeah, yeah. Once baby’s out. But before the placenta. Yeah. So this is one of those interventions where you have to treat everybody to prevent a bad outcome in a small number of people. Yeah, but because it doesn’t for most for the vast majority of people have any negative effects then it’s worth doing. It’s worth doing things like vaccination. Yeah. Treat everybody to protect a few people. Yeah. So doing that in a way in a preventative way said before the haemorrhage happens was one of those great developments in the 20th century that turned having a baby into something that was really dangerous, into something that is now pretty safe. 

Brigid [00:17:17] Yeah. Yeah, yeah. Modern obstetrics people. So is there anything else that you do to prevent it? 

Patrick [00:17:26] There’s lots of other drugs that we can use. And it’s a cascade. Yeah. Okay. So they’re the preventative things. Okay. Identify high risk patients. Be ready to go. Have lots of expertise. Give drugs early. Yeah. Okay. And then there are interventions once the bleedings up and away that range from things that can be done quickly and easily, right up to complex things in an operating theatre. Yeah. But what we find is when a haemorrhage is underway, the quicker we act. Yeah. And the more aggressively we act to treat it, the less likely it ever is to get to the point where we need to do something serious. 

Brigid [00:18:02] All right. So I’m a woman who’s just had her baby and all of a sudden there’s a bit of activity because they think I’ve had a postpartum haemorrhage. What? What happens? What does the room look like? 

Patrick [00:18:16] Yeah, well, there’ll be someone with that woman like that. There might be an obstetrician. There might be a midwife. And the first thing that any trained person would do would be to recognise it and call for help. Yeah. So there’s a buzzer. Push the buzzer and lots of people will come running. And that’s what’s great. That’s scary. That is. Yeah. Yeah. So the dad and the woman and anyone else who’s there, if they’ve never seen a post-partum haemorrhage and trained for are scared by that as all of these people appearing out of nowhere. And when the rest of the team comes in front, go job, someone would get an intravenous line if there wasn’t already one. Someone’s giving drugs, someone’s making notes of what’s going on. Yeah. And someone’s doing other things that can help the haemorrhage to stop. Yeah. So, for example, if the haemorrhage is coming from a tear in the vagina and that’s obvious that that’s what’s coming from then you put a pack in there and squeeze and the bleeding will stop. 

Brigid [00:19:10] Why does it bleed that much as an artery or a vein or something like that? 

Patrick [00:19:14] The tear might come from an artery or vein. If the haemorrhage is coming from the uterus that is too floppy, then maybe it will be giving drugs to tighten it up. Yep. And doing something called rub the fundus, rub the uterus really hard. When you rub it, it tightens. Yeah. And some blood will be going off to pathology and someone else’s job to, um, to ring anaesthetics in case we need an an an anaesthetic to manage it. Ring operating theatre in case we need the operating theatre to manage forth. And you know it’s not this is not a rare thing. Yeah. So we get pretty slick at managing it. 

Brigid [00:19:50] Yeah. And how often can that woman just stay where she’s had the baby. 

Patrick [00:19:54] Most of the time most. Yeah. 

Patrick [00:19:55] Going to theatres not usually necessary. And what you could do is act quickly. Yeah. Give the medications and then by the time they’ll kick in. Bleeding stops. Yeah. 

Brigid [00:20:06] And where’s your baby during all of this? 

Patrick [00:20:08] Mostly there with you.

Brigid [00:20:12] You can hold the baby?

Patrick [00:20:13] Sometimes or in a more serious situation might pass the baby off to to the to partner. Yeah. And then and then obviously you know things can escalate. But most of the time we can fix this quickly and efficiently. 

Brigid [00:20:30] Women who have had a big pph and perhaps needed some theatre management or whatever it might be like, do you see them afterwards? How are they going afterwards? 

Patrick [00:20:39] Yeah, I think it needs a debrief. And I think that one of the challenges in medical life is that things that things that don’t scare us because we’ve seen it all before. Scare the hell out of the patient. Yeah. Yeah. So. Yeah. Debriefing debriefings. Important. I think we go. Okay that probably could do that better. Yeah. So. So people want an explanation. Yeah. Yeah. What was done to fix it up. And then of course they want to know if it is going to happen again.  And sometimes if someone goes home after a significant postpartum haemorrhage. Big mighty decisions like are we’re gonna have another baby months, months swing on the explanation that we give about the risks of next time and what we might do differently next time, because one of the risk factors for having had a postpartum haemorrhage is having had one before. Yeah. So we might treat that woman differently. 

Brigid [00:21:31] Yeah. And I think it’s in now growmyprogram that we talk about, one day will launch people and you can we’re talking about all the time, join the cue. We do have a waitlist. You can go onto our website and join on the waitlist and you’ll be the first to know. One of the things we do cover is debriefing, when perhaps you don’t have a private obstetrician or private midwife or, you know, someone that you’ve had continuity of care with. How does somebody in the public system go about getting a good debrief? 

Patrick [00:22:01] Well, I think from if there’s a major issue like that, they should be offered a debrief. Yeah. And I’m sure there are good ones and bad. Yeah. But I think it’s part of the work of a busy public obstetrics unit to offer a debriefing to people if things don’t go according to plan. 

Brigid [00:22:15] Okay. All right. So is there anything that that woman could be doing differently herself so she doesn’t have a PPH next time? 

Patrick [00:22:24] Well, yes. One of the risk factors is, is, um, being overweight. So coming into the next labour at a healthier body weight is definitely something that can help. Making sure iron intake in the next pregnancy is as good as we can get it so that we come into that next labour with extra haemaglobin, more than you need. Yeah. And that way you can afford to lose a bit and still be fine. And occasionally, but not often. Occasionally big decisions are made about perhaps maybe we’ll have the next baby by caesarean section, for example. Yeah. Yeah. So that’s not always a get out of jail doesn’t work that way. Yeah, but there might be circumstances of a vaginal birth where it might be it might be advisable to at least discuss having subsequent babies by saying yeah well right. 

Brigid [00:23:14] Well I’m just going to recap and say this is a obviously a very serious issue happens, in 10 percent of pregnancies and the key is prevention and knowing your medical team and knowing where it’s at. 

Patrick [00:23:30] And yeah, it’s one of those thing. Postpartum haemorrhage in particular is one of those reasons why you have your baby in hospital. Or why we like people to have their babies in a hospital. And the reason for that is that nobody has any way of knowing where they’re going to have postpartum haemorrhage or not. In the vast majority of cases. And in the hospital setting really is definitely superior to any other setting for the management of haemorrhage when it happens. And I guess if haemorrhage was a once in a blue moon thing, we wouldn’t be so concerned. But we have postpartum haemorrhage every day. Yeah. Yeah. On our public unit. So that’s why we like people in hospital and. Yeah. Go home the next day. That’s fine. Yeah. But haemorrhage is real. It can be dangerous and we can fix it if if people there. Yeah. Yeah, exactly. 

Brigid [00:24:24] All right everyone. Well that’s the end of the episode for this week. I hope that was informative. If you’ve enjoyed our podcast and we know that there’s lots of people listening. I think we’re up to about 50000 downloads so far. Yeah. So if you’re one of those and you want to share it with everybody, we would be very grateful. 

And thanks for listening. We’ll see you next week. See you next time.