In this episode we are covering the definition of postpartum hemorrhage, plus some evidence and stats on PPH with and without pitocin. The biggest reason that providers intervene in the third stage is to prevent postpartum hemorrhage, but we know that active management of the third stage isn’t physiological and so it shouldn’t be the routine! I also share a list of third stage topics that are a must to research for you to feel prepared and informed before walking into the hospital.

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Mentioned on the show:

https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage

https://evidencebasedbirth.com/evidence-on-pitocin-during-the-third-stage-of-labor/

https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm

https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer

https://www.fiercelizzie.com/free

No time to listen? Here’s the gist:

I recently came across a post on IG from a very large account, educating on why hospitals give pitocin routinely. And it was the typical hospital vibe of, this is how we do things, no mention of alternatives, no mention of actual risk numbers so you can make an informed decision, not up to date with the latest evidence or acog definition, and only mentioning the benefits of the providers preferred routine. Of course this was simply a quick info post on IG and I’m sure this nurse does give the required aspects of informed consent in real life. But we still need to talk about it!

What is the definition of postpartum hemorrhage?

ACOG defines postpartum hemorrhage as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of maternal mortality worldwide

For perspective, blood loss around 500 mL is similar to a routine blood donation, a loss of about 2 cups of blood, which is usually well tolerated by healthy people. The blood that is lost after birth is sometimes also diluted with urine and amniotic fluid. There is also an expansion of blood volume that occurs during pregnancy that helps to protect mothers against harmful effects of blood loss after birth (Erickson et al. 2017).

How common is PPH?

Estimates vary widely, depending on which definition of PPH is used. With a routine uterotonic given in the 3rd stage, rates of blood loss >1000 mL range from 0.9%-2.9% versus 2.4%-4.8% without a routine uterotonic (Begley et al. 2019; Salati et al. 2019).

The rate of PPH >500 mL after vaginal birth was 3% in a large study of 8.5 million hospital births between 1999 and 2008 (Kramer et al. 2013). However, the rate of severe PPH that led to blood transfusion, surgical removal of the uterus, or surgical repair of the uterus increased from 1.9 to 4.2 per 1000 from 1999 to 2008.

WHY is PPH on the rise??

Australia, Canada, the U.K., and the U.S. have all reported a recent increase in the rate of PPH, and researchers aren’t sure why (Kramer et al. 2011). It may relate to an increase in risk factors for PPH like more VBACs, more multiple pregnancies, and an increase in induction, augmentation, and epidural use. Unfortunately, there is very little evidence to support these possible explanations.

Let’s recap.

There is a huge discrepancy between 500mL vs 1000mL definition, most are visual estimates and judgment calls, providers are fearful of PPH and typically do not understanding or trust physiological birth, the amount of interventions on the rise, interventions also carry a risk of PPH, maternal mortality is recently on the rise, (seriously, 17, 20, 23 per 100,000 live births in 2018, 2019, and 2020 respectively) AND evidence doesn’t really support one option more than the other.

Bottom line is you need to know what you want for the 3rd stage. Honestly, I have zero trust in what is happening for third stage management in hospitals now. This is often a time that gets missed, either because mom doesn’t research beyond baby being and also because during the third stage mom is busy with baby and may not notice or advocate as well during this time.

Third Stage Research List

You are going to research expectant management (hands off or wait and see) versus active management (all the interventions preventatively). 

• skin to skin

• the breast crawl

• delayed vs immediate cord clamping

• cord traction

• fundal massage

• pitocin in 3rd stage

• postpartum hemorrhage

• retained placenta

Want to know more about what you need to research for birth?

You need to be ready because intervention is the norm for the hospital birth. And we can do birth so much better than the standard hospital routine. It starts with being prepared. I want you to walk into the hospital knowing what to expect, knowing your options, and feeling empowered. That’s why I am hosting a FREE 3 day birth class for you- all about EMPOWERMENT in your hospital birth.
This is a no BS, hold your power, take control of your birth type of class. Take Back Your Birth starts March 23 and you are invited!

Here’s what you’ll learn:

• Why your body and baby want you to birth unmedicated and how to do it.

• Some of the common hospital routines that you need to know about and your alternative options.

• Your birth rights and how to advocate for the birth you want.

This may be the best free birth class I have ever hosted. Go grab a seat!

Last thing, if you want a true hands off third stage, your provider should simply watch for the signs of hemorrhage and your placenta will come on its own. There’s no reason to think your body will fail in birthing the placenta when it just birthed a whole baby unmedicated.