“Postpartum Hemorrhage!” – with Dr. Samantha Do

Dr. Nathan: Welcome to today‘s episode of “Healthful Woman”, a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman”, I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Samantha Do, welcome back to the “Healthful Woman” podcast, great to see you.

Samantha: Great to be here. Thanks for having me.

Dr. Nathan: You almost got out of this today because I was busy in the office. I ran to do a delivery and you thought. But you can run but you can’t hide. 

Samantha: I tried.

Dr. Nathan: Excellent. How’s everything going for you?

Samantha: Going really well. It’s been really nice to get integrated into the practice more, family bring delivery more, get to serve our wonderful patients.

Dr. Nathan: How’s it been in labor and delivery? Because this is your, I guess, first year at the Monsanto labor floor?

Samantha: It’s been great. The nurses have been really supportive, the other doctors really supportive. It’s really a nice patient experience, I think, a nice place to deliver babies.

Dr. Nathan: Well, any big differences that you notice between, let’s say the New York City hospitals versus California where you were last?

Samantha: Space. Rooms are smaller, true to Manhattan form. There’s a premium on space, but beautiful views of Central Park.

Dr. Nathan: Right. Our buildings are built vertically, not so much horizontally.

Samantha: Yeah, that’s definitely Walk a Mile going flat [inaudible] another hospital here up.

Dr. Nathan: You’ve gotten rave reviews on the labor floor from the patients, the doctors, but most importantly, the labor nurses. And if you’re accepted into their society, you are made in the shade.

Samantha: They do know what’s up, the guardians of keeping patients safe. We like them.

Dr. Nathan: It is critical. And those who are with them are doing well, and those who they do not like are in big trouble.

Samantha: When you care about patients, they want things to go well.

Dr. Nathan: Yeah, very good. You’re being very kind. We’re going to talk to you about postpartum hemorrhage or bleeding after delivery. And, pretty common, right?

Samantha: It’s one of the most common things that we think about for all patients and that we prepare for all patients.

Dr. Nathan: Yeah, and it gets a lot of press for good reason. It in the world is one of the causes of maternal mortality of women dying in childbirth. Fortunately, that is not common in the U.S to die from hemorrhage, it’s actually moved down on the list. But it is a potential problem for anyone who has a baby.

Samantha: And that’s why we’re so aware of it, and we think about it, and part why it get so much press. And thankfully have a lot of really effective strategies to mitigate the risks here in the U.S.

Dr. Nathan: Right, so we’re going to talk about it. And again, one of the interesting things about postpartum hemorrhage and everyone is talking about it, but it’s strangely very confusing for people. And I think one of the reasons it’s confusing is, we don’t have a clear definition of what it is, meaning how do we decide if someone has it or doesn’t? And number two, and which we’ll talk about, quantifying how much bloodstone is lost is very challenging. It’s not an easy thing to do. And part of the reason it’s hard to define it is because we can’t really quantify that well.

Samantha: There have been all sorts of attempts to try and quantify it. And we’re still not that good at it. And it’s interesting that there’s so many different definitions about it, and what really matters in terms of the definition, even that we’re using standard in the U.S has changed in the last four years, pretty dramatically. We used to say, after a vaginal delivery, it was normal to lose half a liter of blood, 500 CCs, which looks like a lot to patients, kind of, even a normal amount of blood loss for delivery seems like a lot, but the body is well designed in compensating for it by having more blood volume in pregnancy, getting ready for that natural loss.

Dr. Nathan: Right. Right, one of the nice things about pregnancy is it tends to happen in younger, healthier women. And by younger, healthier, what I mean, you know, under 50. So women, you know, their hearts tend to be fine, and they can tolerate blood loss. And during pregnancy, that blood volume increases a lot. So you can lose a half liter or a liter of blood when you’re pregnant and actually not notice it so much, which is remarkable. Because if that happened to, you know, a 75-year-old man in a car accident, it could be horrifying to lose that much blood.

And so, the definitions in the World Health is more than half a liter. In the American College, it’s more than one liter with symptoms. If you look in England, they define it as minor, moderate, and severe. If you look at California, they have…you guys really went wild out there with stage zero, stage one, stage two, stage three. I mean, there’s all these different criterias and grading systems, but the simplest way to think of it is, you’ve lost too much blood. That’s it, you know.

Samantha: Yeah, you’ve lost too much blood because this is not what your body likes. And so we’re looking out for the symptoms that you’re having too much blood loss and signs in terms of changes in your heart rate and your blood pressure. And those are really the things that we want to respond to or respond to before they happen if we can anticipate they’re going to happen.

Dr. Nathan: Right. Clearly, the more blood someone loses, the more likely it is their body won’t respond well to it. And so, yes, we do keep an eye on the number and we think it’s a certain amount, we think it’s reaching them out. But ultimately, it only matters if the body’s having a problem with it. Meaning, if I didn’t know the number of what someone’s blood loss was, but they felt fine, their heart rates fine, they’re doing okay, they’re recovering okay, it doesn’t really make a big difference, because after delivery, their blood count will start to go back up over the next days and weeks and months.

And on the flip side, if we don’t really know, and it doesn’t seem like so much, but their blood pressure’s low, their pulse is fast, they’re not making urine and they look very sick, we don’t really care. We’re treating the person, not so much the number. That’s a big tenet that we train the residents. Like, we’re not treating a number, we’re treating the patient, we’re treating the person. And so that’s really the more important part of it, but it’s the things we look out for. So the more blood someone is losing, we’re gonna start really checking to make sure that they’re doing okay, what we say physiologically.

Samantha: And in some ways, that’s why it doesn’t matter as much that we’re bad at quantifying it in absolute numbers. It makes it really hard to study, it makes it hard to have definitions of. But as long as we’re with the patient, as long as we’re looking at you, as long as we’re watching what your numbers are doing, but also how you’re feeling in person, we can have a sense of how things are going and keeping them safe that way.

Dr. Nathan: Right. And so, for our listeners who are thinking, “Okay, you know, if you lose too much blood, I understand conceptually that that’s bad. But what exactly are the things we’re worried about?” And I think that the first thing and the simple thing is just symptoms. It’s harder to recover from a delivery if you’re very anemic, because you can’t get out of bed because you’re dizzy and you’re weak, and you’re tired, you just feel like you’re running on a half tank of gas or less.

I mean, that’s what it is. The blood is what gets oxygen to your tissues. And so, if you have a very low blood count, you’re not getting the right amount of oxygen to your tissues, and you’re weak. It’s also part of your volume in your blood, which sort of like perfuses your brain and so you feel weak and dizzy, like you’re gonna pass out. And that’s, I think the most common of the complications and the most annoying for people.

Samantha: Having just delivered a baby is exhausting enough as it is, then being anemic on top of it is something why we watch out for. It also makes breastfeeding harder, there are lots of good kind of symptomatic things that we’re looking out for. And then why we care is if it gets to such a point where you’re severely anemic that women can actually need a blood transfusion. Blood transfusions are really safe, they’re screened in the U.S really thoroughly so that we’re only given kind of third screened blood, that’s safe with really low risks to it. And they can make women feel a lot better in terms of those symptoms that you’re talking about.

Dr. Nathan: Yeah, and I agree, I mean, transfusion is considered like in medicine, or in obstetrics, a bad outcome, so to speak. But it’s not a bad outcome because it’s dangerous to get a blood transfusion. It just means like, it’s a bad outcome because you bled enough that you needed a transfusion. It’s more of an indicator that you bled so much. It’s not that, “Oh my god, we’re giving blood. That’s so terrible.” Because, again, like you said, it’s so safe, we’re not really concerned about giving someone an infection. Obviously, they check the blood like 6000 times to make sure you have the right type and it’s not going to have a reaction in your body or anything like that.

And so, people shouldn’t be afraid of the transfusion itself if they need it. But again, that would just mean that they lost a lot of blood because it’s unusual someone needs a transfusion, unless they’ve lost a liter or two of blood after…and closer to two rather than one. It’s also not that common. I would say, you know, in a typical sense, maybe 1% of women end up with a transfusion after delivery. It’s pretty rare, fortunately, but that would be a consequence also of losing a lot of blood. What else could be? Like, for example, beyond symptoms, beyond getting a transfusion, what’s like the next level like badness that can happen from losing a lot of blood?

Samantha: The worst is if you need a repeat surgery, or you need to be taken to surgery if you’ve had a vaginal delivery, if you’ve lost a lot of blood. And that can be because all of our kind of usual conservative measures like medications and other kind of compressive options haven’t worked to stop bleeding that you need to go to the operating room, which is something we’re prepared for when it happens. Occasionally not very often, but is something that we want to avoid if possible. And in the worst case, sometimes the only way to stop the bleeding is by actually removing the uterus. That’s a very rare outcome to have hysterectomy because of severe hemorrhage.

Dr. Nathan: Right. Right. And that’s sort of when we get into the terms like medically we call it morbidity when like bad things happen to you because you’re bleeding. And the bad things would be, again, transfusions, technically, one of them, well it’s not really bad. But needing to be opened, to have surgery when you didn’t otherwise need it, is a bad thing. Or having an organ removed, like a uterus is a bad thing, particularly if you want to have more children. But someone’s, if they think it’s their last baby, all right, it’s a big deal, and it’s a morbid thing, but it doesn’t have the same consequences moving forward.

But if it’s someone’s first baby, or second baby and they want to have more, obviously it’s a huge deal to have a hysterectomy, which is why we really only do it if it’s life saving. We’re not going to do it, you know, just for the hell of it. And it’s really the last resort. But there’s other, you know, types of interventions. People sometimes go in to interventional radiology and they get catheters, you know, threaded up their groin and they embolize things. Again, these aren’t life or death things but they’re major events to undergo and have their own recovery and their own risks, so that’s another thing.

And, you know, unfortunately like we said, in some places that don’t have access to the right treatments, or if it’s not treated properly, women can die from bleeding too much after delivery. It’s a horrible thing to think about, but it’s part of the reason that we take it so seriously in everybody because you don’t always know who that person is going to be who’s gonna have the crazy hemorrhage. Sometimes you can predict it, there’s risk factors we’ll talk about, but usually it’s unexpected. It just happens. And we don’t always know why, and so we have to be prepared in all cases.

Samantha: The good thing is that we have a lot of strategies before we get to that last resort or before we’re looking at that awful last outcome of demise. It can be dramatic, though, even when it’s even a small amount of bleeding. So I think that’s the other bad thing that we want to avoid and talk to patients about, is just, it’s hard to see one’s partner go through that, it’s hard to go through that.

Dr. Nathan: All deliveries are kind of messy. And it’s generally not a good idea for people to be looking around there because it’s just, I mean, it looks like a crime scene afterwards. And that’s very typical. And a normal, healthy, average, perfect delivery, it’s not clean, like that’s normal. But when someone’s bleeding a lot, and then people are coming in the room, and then you see blood, and then there’s fear, and, you know, that definitely compounds the event for people who are going through it themselves, even, again, if everything works out fine.

People ask, “How often does this happen?” And it’s also one of these things because it depends on how you define it. And so if you have a more, let’s say, lenient definition, where you’re more likely to call it a hemorrhage, obviously, the likelihood it’s going to happen is going to go up versus if you’re more strict, it’s going to go down. I tell people, it’s usually a couple percent, 2%, 3% of people or 5% maybe, somewhere in that range 1 to 20, 1 to 25, 1 to 30 deliveries is going to be like a real issue with bleeding you have to take care of. And also it depends on what the population is. If you’re taking care of a lot of, you know, people who are carrying twins, you’re more likely to have them versus people are not carrying twins.

Samantha: One of the main reasons that people have extra bleeding after delivery or hemorrhage is that the uterus isn’t contracting down as well as it’s supposed to after delivery. And things that stretch out the uterus more to start with, like having two babies or three babies or multiples are one of the reasons why the uterus has a harder time contracting back down. And that leads to what we call uterine atony, the muscle after delivery, after the placenta comes out is going to contract out normally to prevent bleeding from that site where the placenta was. And then when it’s stretched, it has a harder time at that.

Other reasons that you can have atony, the uterus isn’t contracting down as well, is if the uterus has been more stretched out by having extra fluid at the time of going into labor, like, with polyhydramnios, having extra amniotic fluid around baby than you’d expect, or having a bigger than average baby, a baby that’s large for their gestational age could be another reason to have more atony.

Dr. Nathan: It’s really one of the most amazing processes there is, if you think about it, that the uterus and the placenta and the woman’s body change during pregnancy in a way that allows a tremendous amount of blood flow to go to the placenta and towards the baby during pregnancy. Meaning, every minute, there’s about a liter of blood going to that placenta. That’s a tremendous amount. And so you have these massive arteries that have a huge amount of blood flowing through them like high flow like garden hoses coming towards the uterus. And then suddenly, in a matter of minutes, the placenta just gets taken out, and all of those arteries have to stop doing that. Otherwise, they’re just going to keep bleeding and bleeding through the uterus and come out.

And it doesn’t stop from the typical way bleeding stops. Like, if you or I get…you know, we fall and we scrape our knee and it’s bleeding, the way it stops is that, you know, our body senses it and it sends these little like platelets and fibrin and things that go plug the hole and put in, stop the bleeding and put a scab there. And that’s sort of what typically happens. But here, that’s not going to work because you’re talking about blood vessels the size of like your finger. Like there’s no way that platelets are going to plug that hole. And so what our bodies have designed, at least those of us with uteruses, is that the uterus, the muscle clamps down and contracts very quickly and very strongly to sort of squeeze those hoses shut, like, as if like you’re stepping on the garden hose.

And anything that prevents the uterus from doing that, if it’s very relaxed, the muscle is relaxed, there’s no way that bleeding is going to stop. And so that’s why it’s the number one cause of hemorrhage, the uterus being relaxed, which we call a tonic, which means not having tone. So we say uterine atony, that’s the term we use as obstetricians. But it’s by far the most common clause. And we almost assume it’s the clause unless someone tells us there’s another thing. And that’s why we always start treating that right away.

And many of the things we do, are meant to treat that, to prevent it, to treat it because it is by far the most common cause of bleeding after delivery. Like, you know, more than 9 out of 10 times it’s going to be that, probably 95 out of 100 times, that’s going to be the clause. And like you said, that also affects the risk factors for it. So anything that would make the uterus weak or overstretched or something like that, it’s less likely to clamp down. One of the interesting things is, as women have more and more babies, not in one pregnancy but as they have their third kid, their fourth, get their fifth kid, let’s say, the uterus, it just doesn’t contract as nicely. And so we see this more commonly in women having a fourth, fifth or sixth kids compared to their first or second.

Samantha: It doesn’t seem fair, in that unlike other muscles that the more you use them, the stronger they get, the uterus, the more pregnancies you have, the less likely it is to contract down well. And so we even more prepare for uterine atony in not contracting well.

Dr. Nathan: Yeah. And it’s not just a function of age, right? Because it could be, you think, all right, if you have more babies, you’re also getting older, and our muscles get weaker as we get older. But it’s really not from that. It’s the idea of having more babies, for whatever reason the uterus gets less efficient to clamping down after delivery. It gets more efficient with the labor, which is interesting, because labor’s are quicker, babies come out quicker. But afterwards, the uterus is like, “All right, I’m done, I give up.” And so it is more common, and sometimes we sort of give more medicine preventatively after delivery for someone who’s having a fourth, fifth, or sixth kid, compared to someone having their first, second, or third, because of that risk.

Samantha: And while the uterus is not clamping down, uterine atony, is by far the biggest reason why we have a hemorrhage and why we’re always preparing for it and looking for it, some of the other big reason that the body is actually smart at preparing for is having tearing, very normal to have kind of tearing at the time of delivery and blood loss from that. So repairing that tear can often decrease that blood loss and not make it be too much. The body is also preparing for those kind of little cuts that happen by increasing those things like clotting factors or the things that the body sends as its barrier to try and decrease blood loss. So it’s why we think about women are being at increased risk of blood clots in a bad way in pregnancy. It’s also the body’s trying to be smart and prevent having too much bleeding at the time of delivery.

Dr. Nathan: Right. And there are women who have disorders of clotting where they bleed. And they do bleed after delivery because of that. But interestingly, a lot of that ends up being sort of delayed, meaning not immediately at the time of delivery, but frequently, like days or weeks later, when the bleeding isn’t so much because the uterus is clamping down, but from regular clotting. There are extreme cases when women bleed at delivery from having factors missing. Or sometimes women, if they’re bleeding a lot, they’re bleeding out those factors. And so they don’t have a problem other than they‘re not in their body anymore, the factors.

And so we have to start replacing factors, in addition to other things we’re doing for women who are bleeding a lot. There are other some unusual causes of postpartum hemorrhage that are not related to this that we think about and we check for, things like a uterine inversion where the uterus sort of comes out inside out, which is a very strange thing. But it happens rarely [inaudible] cause bleeding or a uterine rupture. Like, if someone had a prior C-section in labor where the uterus is contracted, but that scar is now not intact, and so it’s bleeding from there. And then sometimes people have an unexpected placenta accreta, where the part of the placenta stuck to the uterus and didn’t come out. And that sometimes it causes bleeding, then it could cause bleeding later. But these are more rare compared to the other causes.

Samantha: Things that we would check for and watch out for these less common. Things that are more common are just that you were in labor for a long time, and even if it’s a first baby, the uterus having contracted a lot during a long labor doesn’t want to clamp down as well. Or if you have an infection in labor, the uterus is injuriously bad at contracting down after an infection in labor, so things that we would watch out for if possible.

Dr. Nathan: This is one of the consequences of our sort of acceptance of longer labors. Meaning, in the past, doctors were very unhappy by the labors that were not going according to schedule. Like, “Hey, you’re not dilating quick enough. It’s a problem. Let’s do this. Let’s do this.” And I think, with good reason, we’ve gotten a little bit more lax with that and saying, “Okay, if the baby looks fine, you look fine, we’re gonna let your labor go longer.” And we’ve got a lot of studies showing that it’s safe for the mother or for the baby to wait. And I think that’s a good thing, and it can lower the C-section rate.

But it’s well known in all those studies, that the longer labor is one of the consequences is a much higher chance of infection and bleeding after delivery. And so it does not tend to lead to the horrible consequences because we know about it, but it certainly increases the risk of going through an event like this, maybe sort of that traumatic experience of hemorrhaging or needing a blood transfusion or more medications or maybe even a procedure or something. So that’s something just to keep in mind with this notion that longer labors are really, really good because it lowers the C-section rate, which is true, but there is a downside to it also, which is, you’re a higher risk for this.

Samantha: It’s everything in medicine of trade off of the risks and benefits. And certainly I think worth being patient with labor, worth being patient with pushing because things can naturally take time. But preparing for the flip side of it, which is an increased risk of bleeding infection having just high risk on that front.

Dr. Nathan: So what exactly do we do on our end, right? We know this is a problem, we know that there are risk factors but for most people, it’s unpredictable. It just happens and we know that it can be catastrophic, it can be problematic. So what do we do to help them with this either to prevent it or to treat it?

Samantha: The first thing we want to do is set everyone up for the best chance of success by going into labor and delivery with the best blood counts that we can have for them. So, anemia is really common in pregnancy, because you have this other being who is stealing your stores of iron that you use to make red blood cells. So it’s very common to get a mild anemia in pregnancy. And a mild anemia isn’t so dangerous for going into delivery.

But we want to prevent kind of women having severe anemia going into delivery. And how we do that is by checking what their blood counts are, and trying to find the cause of it. Often, it’s just someone who’s stealing their iron, babies stealing their iron. So giving them iron supplementation, either by mouth, if that’s working well, or by IV if they need, and then making sure that’s helped, or finding other causes that they might have low blood counts, might have anemia going into delivery.

Dr. Nathan: Yeah. And I think that that’s a really important part that a lot of people don’t understand, like, why do we care so much about their blood counts? Why are we checking them? Why are we giving them iron? Why do we go so crazy about this? And it’s not because anything bad is gonna happen to the mother or their baby during pregnancy. Like, the blood count they’re walking around at is fine. Like it’s safe for them, it’s safe for the baby, they’re not going to feel any symptoms, they’re going to be perfectly okay.

But we just sort of know that when they show up on labor and delivery, think of it if you’re going on like a road trip. If you can start your road trip with a full tank of gas, it’s going to be better than if you start with a half tank of gas in terms of how often you have to stop and all these things and what have you, traffic. And so for us, it’s the same thing as someone comes into labor and delivery with a higher blood count, her body has more capacity to tolerate blood loss. And so you have two women who have the same blood loss at delivery, but one starts with a much higher blood count, she’s gonna feel better after delivery, and she’s less likely to need a transfusion or all these other treatments.

And so it’s just that. It’s really starting labor with a higher count. It’s very rare that the anemia itself before labor is dangerous to her. I mean, it’s very rare. You have to have almost like a like a blood disorder to get that low in pregnancy that you’re going to notice it or it’s going to be a problem. But it’s more so when you deliver. Whether vaginal or C-section, you’re going to lose blood. And if you start low and you lose blood, you’re more likely to have issues because of it.

Samantha: Completely about setting up for success at the time of delivery. And the other thing is by looking out for who is at higher risk at the time of delivery. So kind of those things we talked about before of having more descent of the uterus, multiple babies, having had multiple babies in the past, being third or fourth or fifth delivery and not the first, looking out for those risk factors and preparing at the time by maybe having extra medications available, by maybe having [inaudible] just in case most of the time we end up not using it but just repair for all the options.

Dr. Nathan: Right. And also, a lot of women will come and say, “Oh, my last delivery, I bled a ton, and they had to do this, had to do this, had to do this.” And having a history even in one pregnancy, definitely puts you at increased risk of the next pregnancy. And so there are things we do routinely in all women at delivery or after delivery to prevent this. And that’s the reason we give the pitocin, the oxytocin after delivery. There’s different ways to do this, most places in the U.S are going to give intravenous oxytocin, which is pitocin, the same thing we use to induce labor. It’s the natural hormone that the body makes. And why do we give this after delivery?

Samantha: Really to help the uterus contract down. And it’s been shown time and time again, compared to not giving any medications that it’s really effective to give pitocin or oxytocin right after delivery of baby to decrease blood loss. It used to be given kind of after delivery at a while for only people at risk. And then they found that it’s actually helpful for everyone to give oxytocin after delivery to decrease.

Dr. Nathan: Right. And there doesn’t really seem to be a downside. People have looked at this in all different ways. It doesn’t seem to affect the mother or her health, it does not affect breastfeeding, it does not affect the baby, it really doesn’t affect anything. The only downside is, you’re going to feel more crampy, particularly if you don’t have an epidural. But that’s actually a good thing. It’s not good to feel the pain but it indicates that your body’s doing what it’s supposed to be doing because that crampiness, that pain, that contraction is the uterus contracting down and stopping the bleeding.

So if someone has an epidural, they won’t notice it typically, at least in the first few hours after birth. And if they don’t have an epidural, this is what the body is supposed to be doing. Meaning, if you don’t feel any cramping after delivery, your uterus is relaxed, and you’re probably going to bleed a lot. And so it’s one of those things where it’s like, this is what is supposed to happen, and giving the oxytocin definitely lowers the risk of bleeding, transfusion. Any outcome you think of relates to bleeding, it lowers the risk. And frequently you’ll see one of us potentially sort of like rubbing the belly. And what is that? Is that like a like rubbing the fortune ball?

Samantha: We call it fundal massage or if that’s the top of the uterus, uterine massage. It sounds when you say massage, like, then it would be comfortable and wonderful.

Dr. Nathan: Or it’s lovely.

Samantha: It’s really not the most comfortable thing, but it’s for the purpose of helping stimulate the uterus to contract back down.

Dr. Nathan: Right. Like a deep tissue massage. Not so pleasant.

Samantha: That in combination with kind of expediting delivery of the placenta, sometimes patients ask me, “Do we not just let the placenta take its time to deliver on its own?” Is that the placenta when it’s there, it’s preventing the uterus from contracting down. So helping the placenta to gently deliver allows the uterus to contract down and close off those big kind of garden hoses, those sinuses feeding the placenta.

Dr. Nathan: Yet for whatever reason, the uterus after delivery is very sensitive to touch that if you rub the uterus, it will contract down. And we usually do that externally like through the mother’s belly, like we put our hand on her belly and sort of feel, you can feel the uterus and rub it. Occasionally you have to do what’s called bi-manual where one hand is internal in the vagina and the other hand’s on the belly. That’s a more vigorous, obviously, event and certainly, much less comfortable, if you don’t have an epidural. Someone who has an epidural tends not to be so bad. But that’s another way to do it.

It’s very effective in terms of getting the uterus to contract down because it does respond to that, particularly with the oxytocin. And then one of the other routine measures we do, and this one we’re talking about before is, we try to figure out how much blood has she lost? Like, what is it? You know, is it 200 milliliters? What we call CCs for cubic centimeters, that’s like a medical thing. It’s, you know, from whatever, it’s the metric system, that’s how we measure fluids. Is it 400, is it 600, is it 1000 which is a liter?

And it’s very hard to do accurately, because there’s a lot of other stuff going on there. The blood can get absorbed in the sheets, or in these towels or pads that we use. It could be on the baby, some could be on the floor potentially. Also, there’s amniotic fluid that gets mixed in. So if you see a bag full of red water, you don’t know how much is blood, how much is amniotic fluid. And so it’s very hard to figure that out. And people have tried all sorts of systems to do this. I mean, what systems have you been in your career, right? I’ve been through like eight different systems, what have you been through?

Samantha: I’ve only been through two which, one is, just the visual estimation. We have a drape that has gradations on it to try and measure it, and you look and you try and see. And then the [inaudible 00:26:41] way of trying to weigh things and quantify it and have a sense of what’s amniotic fluid and what’s blood. And neither are particularly accurate when they’ve studied them. Something is better than nothing, though, trying to measure it and assessing it is always better than not assessing it, even if we’re not that good at the actual numbers.

Dr. Nathan: Yeah, I think when I started, literally it was just, “Doctor, how much blood did she lose?” And say, “About 400.” And like that was it. And then they went to, “Okay, we’re going to trap everything that comes out in his bag, and we’ll look at the bag and say, ‘Okay, that’s how much is in there and try to guess how much is blood versus amniotic fluid and do that.’” Then they started saying, “Okay, now let’s look at all of the sheets and towels and what we call lap pads and stuff that have blood on them and look at them, and if they’re 50% saturated, it’s this much and you start adding up these numbers.” And then they started weighing them like actual weights.

And then they start doing this new system they have where it’s almost like a one of those like scanners on your iPhone where it looks at it, and it measures the volume and the density and it comes up with a number and…I don’t know. I mean, all of it’s inaccurate, and it’s hard to really know for sure. But again, most of these things fall in line together when you think there’s a lot, the machine thinks a lot, it looks like a lot, it’s probably a lot. When there’s huge discrepancies, nobody knows what to make of that. When I think it’s a ton and the machine says it’s a little or vice versa, everyone knows that it’s hard to do. It’s hard to quantify things. And when you think about it, it’s like if you took a bowl of anything, of soup and like threw it on the floor somewhere and said, “How much is that volume?” It’d be like, “Huh?” I know, it’s like impossible. But that’s something we tried to do, and it’s ongoing to try to figure that out.

Samantha: And they try and teach, you know, obstetrics residents to look at it and be able to measure it. And they found that really, people get worse at it over time. You teach them and they forget to like be able to tell how much is on a pad when you spill that amount of red water on it. It’s hard to do, but really looking at the patient is something that we all know how to do and that we do over and over again, which is to see what she’s feeling, kind of what she’s telling you what’s coming out of the vagina and how the uterus is feeling, how the tone is doing. And that’s something that then isn’t just a one-time event, it goes on throughout the postpartum, and of the nurses, the doctors are checking mom’s abdomen, that’s kind of when we feel your belly to see how the uterus is doing. Is it still firm? Is it still clamped down that muscle?

Dr. Nathan: Yeah, I mean, so much of the hemorrhage happens right at the time of delivery. There is a percentage of it that’s delayed, either an hour, two hours, a day, a week, whatever. But at the time of delivery, so much of it is just clinical skill. It’s the doctor, the midwife, the nurse, whoever, looking at the patient. It seems so simple and so basic when we’re saying it, but it’s amazing that there people don’t do this where you just like look, you know, how does she look? Does she look well? Does she look like she’s very weak and sweaty? And, you know, what is her pulse? And then we’re looking at the bleeding. Does it seem normal? Does it seem like a lot? We’re feeling the uterus. Is it soft? Is it firm? We’re looking at the tears. Are there a lot of them? Are there a few of them? Are they bleeding? Are they not bleeding? And we continue to do this.

And it’s also like if I have a woman who let’s say it’s her fifth baby, and typically in a fifth baby, she doesn’t push for very long. There’s usually no tears or very few. And so the whole thing’s very quick. But the sort of the inclination is okay, baby’s out, everything’s good, let’s leave, all is good. I usually stick around because these are the women who are gonna start bleeding five minutes later. So I’m usually there, take more time, talking, cleaning, checking the uterus, stay in the room, you know, hold the baby a little, because I know that things happen in these women, whereas someone else who had her first baby, just because I’m doing a repair, I’m gonna be there for 15, 20 minutes anyways. And it’s just, people understanding these things is much more important than a nurse saying, you know, “Oh, this is the number of how much blood she lost,” or something like that. And, I don’t know, that’s what I found.

Samantha: And like we talked about young, healthy women can often compensate. So really looking at both the numbers of how they’re doing but sometimes they are not showing changes to their vital signs, their pulse, their heart rate, or their blood pressures until things have gotten really too hard down the road of a hemorrhage. And so, yeah, looking at the lacerations, looking at how the uterine tone is doing, and what the patient’s telling you.

Dr. Nathan: Right. And so the final part I want to talk about is, okay, so let’s say you’re at a delivery and she is bleeding more than you would like. It seems like she’s hemorrhaging, it’s either started or it’s in the middle of it. What do you do? Like, what are your treatments that’s available? Other than the things you’ve already done, you know, the oxytocin’s going because it’s routine, and you’re already doing the fundal massage. What do you do at that time?

Samantha: We have, thankfully, a lot of options. And the first next step usually is to add medications. And there are a few different medications that we can use that help the uterus both contract down, like things like we call methanogen or Hemabate are some of the names for them that are working through different receptors, different channels, and the oxytocin to help the uterus contract down. Those are medications that are given as injections. Often, mom has an epidural, they’re given in their leg, they’re not that painful. They’re small injections to begin with. The other option we have is a medication that we sometimes use for induction of labor, or getting women into labor, which is called misoprostol, that also helps the uterus contract down.

And we can give it through a number of different ways. And that’s another nice way of helping the uterus to not have atony. And then the last kind of medication that we think about is a newer medication that’s been used a lot for kind of hemorrhage outside of pregnancy. And now as we’re studying this big trial, the woman trial, and found to be effective for decreasing blood loss which is TXA or Tranexamic acid. There are a few reasons why we can’t give these medications to different women, so we’re sensitive to those.

But if we anticipate there’s gonna be hemorrhage, they’re ones we want to have close by, and ones we’re able to give soon. And the other thing that is really helpful is we’re starting to get more medications, kind of letting the whole team, letting people know that we’re having more blood loss so people can prepare and think about things like the anesthesiologists and other nurses on the floor, so they can be aware of what’s going on.

Dr. Nathan: Yeah, it’s definitely a team approach. And I think that for most women, if it’s recognized in time, and people are on top of it, generally it can be solved with medications alone. And whether that’s extra oxytocin, whether it’s an injection of a new medication, whether it’s giving them misoprostol or the TXA, and it is newer, and it is pretty cool, because TXA sounds like a speed bike or something like that. So people like saying, “Give her the TXA.” You sound like, you know, you’re a fighter pilot or something like that. But it works. It’s a really good medication, and now, as you said, it’s been studied in pregnancy, specifically for delivery. And that’s going to work most of the time for people. And the medications, the nice thing is, they’re pretty safe.

Again, there’s some women who can’t get some of them, and we know that and we don’t give it to them. And, you know, give, you know, the right medication to the right person. There’s not a lot of side effects. Again, other than the cramping, which is, again, the desired side effects. So it is a side effect but it’s actually like a positive sign that they’re having that. There isn’t a lot of risks to giving these medications, fortunately, and they tend to work. And many of them, you can continue for the next, you know, hours or days in some capacity if you need to. What if they don’t work? What’s sort of the next step that you might go to that women have maybe heard or experienced or whatnot?

Samantha: The next thing that I think about is helping the uterus contract down through other means. One of them is actually just draining the bladder, because sometimes a full bladder pushing on the uterus. If you have an epidural especially, it can cause the uterus to be a little bit sluggish about contracting down. So draining the bladder by just putting a small tube in the bladder helps the uterus contract down. And the other is compression kind of from inside the uterus working its way inside out. And that’s what we call a balloon. It’s been used in ultimate ways, but one of the ones we use is called the Bakri balloon. And that’s a balloon that gets put in through the vagina into the uterus and gets filled with water or saline that helps compress those sinuses, those garden hoses so that they’re not bleeding. And it’s really effective.

Dr. Nathan: Right, right, from the inside. You basically like refill the uterus, it’s like putting a fist inside the uterus, essentially, it sets the balloon ends up being this size. And we leave it there for like 12 to 24 hours and it sort of lets everything stop bleeding, then the uterus can sort of like recover and start naturally contracting. And the nice thing about the balloon is it’s not surgery, right? We do frequently take people to an operating room to do it but just because, you know, we’d stop, it’s a bigger room, it’s not an operation. We slip it in through the cervix which is already open because she just had a baby so it’s not again particularly painful for it to happen. Frequently, she has an epidural anyways.

We inflate the balloon from the outside, so it’s inflated in the uterus. But it also, it’s like a dual channel. It has on the tip of it like a drain. So if there’s bleeding that’s going on inside the uterus, it’s going to drain out through a tube into a bag, so we can see how much is there. And once it’s pretty clear that there’s very little bleeding, we’ll start to deflate the balloon either completely, or maybe halfway and see what happens. And usually the next day, deflate the balloon, take it out, all is well. And she’s better and it’s given her a day recover. If we need to give her blood, we’ll give her blood, give her other medicines, and it sort of stops the bleeding acutely and quickly, and lets things sort of settle down and we can sort of, then let her get to the next day without bleeding. And then you can usually just take out the balloon. It’s a really good device.

Samantha: It’s been shown to be so effective at decreasing the need for surgery, the need for hysterectomies, decreasing those things we really, really want to avoid.

Dr. Nathan: Yeah, I mean, when I was a resident, it was right before the Bakri came to Mount Sinai. It was around the time it was getting invented, I think. That may be false, but I think that’s correct. And when I was a resident at that time, it gets operated. Like, that was it. If the medications didn’t work, you’re basically going to, you know, take an operating room and potentially do a hysterectomy. And this has greatly reduced the need for that. I mean, it’s so much less likely that we have to do a hysterectomy because of this balloon. There’s other devices that are similar. There’s a newer one where actually it’s the opposite. It puts like suction on the uterus and like pulls the uterus together, which is pretty cool that’s been studied.

And there’s other types of balloons but this is the one that we use. And if that doesn’t work, we’re really going to more pretty crazy things like either going to interventional radiology for them to maybe what’s called embolize. That’s so they sort of like stop blood flow to the uterus, which has definitely some effectiveness. It’s a big deal to have, it doesn’t always work. It’s a lot of hoopla to get someone to the interventional radiology suite and they’re bleeding at the time. And it’s not easily done but it’s a possibility.

And then there’s surgery. Having surgery does that mean we’re going to take out the uterus. There’s things we can do to the uterus to sort of compress it and hold it squeezed, so to speak, with sutures and things. But there’s always a possibility that someone’s gonna need a hysterectomy if we have to open her up after delivery. And that’s certainly not desired. But again, this is last efforts, you know, life saving measures, so to speak.

Samantha: And we’ve been talking mostly about kind of when the uterus doesn’t contract out, it is the primary main driver of postpartum hemorrhage, uterine atony. Some other things. If there’s bleeding from the vagina that’s not responding to just the normal sutures that we’re putting in for the repair. Sometimes we put [inaudible 00:37:28] in the vagina, it just helps compress that and also kind of just let things quiet down.

Dr. Nathan: Right. Sort of like the balloon but not a balloon.

Samantha: Yes.

Dr. Nathan: Yeah, just like towels or, you know, cloth or whatnot in the vagina. Sometimes that helps.

Samantha: Just helps things settle. And then kind of for those other rare causes, if there’s placenta that’s still inside but not actually invading into the muscle of the uterus, it’s just kind of there, kind of helping it come out, either with a kind of gently manually helping it come out or with a small procedure to help that kind of extra tissue that doesn’t want to come out come out, that’s preventing the uterus from contracting down. Or sometimes in the rare event that it’s attached to the uterus abnormally, and we didn’t suspect it beforehand, like a placenta accreta, now that’s where we think about more invasive measures.

Dr. Nathan: Right. And one of the other things that has really reduced the rate of mortality of dying from this in this country and other developed countries is this implementation of something called a mass transfusion protocol, which is where we were talking about before about giving blood or other products that you lose when you bleed, you know, your platelets and your fibrinogen, and things like that. And there was a recognition from other sorts of trauma surgery, where if someone comes in after a major car accident, and they’re, you know, they lost a limb and are hemorrhaging, that, if you early, give a lot of blood to them, you know, literally just pour it into them, you’re going to lower the chance of them dying significantly.

Instead of like giving a little and seeing how they do and giving a little more and seeing how they do, which you think it should be judicious, but it actually doesn’t work because they’re bleeding so much and you fall behind, and the more behind you fall, the worse it gets. So these started getting implemented in obstetrical hemorrhages. Every hospitals are on protocol for exactly how much they give over how much time and, you know, what ratio of this product to that product. But basically, it’s the concept is, give a lot, give early, give often for a massive hemorrhage.

And that is one of the reasons there’s a difference in maternal mortality from country to country. It’s not necessarily the skill of the doctor, it could just be having a blood bank that’s able to pull this off. If you have a blood bank that can send up 10 units of blood and this and that within 15 minutes, you have a higher chance of living than if you don’t have a blood bank that could do that. And it has nothing to do with the doctors or the medications or the knowledge or anything, it‘s just a resource that’s available.

Samantha: Yeah, and really preventing getting into that spiral because when you get behind then it makes everything bleed more. And so by replacing kind of those blood products, not just the red blood cells but also the other components of blood, really, it’s been shown to really be life-saving.

Dr. Nathan: Yeah, and it’s a scary situation to be in, you know, to say, “I’m getting a massive transfusion protocol.” But again, it is life-saving, similar to surgery. And I think that, again, the main takeaway points I would say from this, is the first thing is that, this is common and it could happen to anyone. I mean, obviously, we said there are risk factors, and as people we’re more suspicious going to happen than others. But we think about this on 100% of the deliveries. There’s nobody we don’t think about how much blood are they losing because we’ve all seen it happen to the lowest risk person. Again, it’s not meant to scare people because it’s not a common thing, but it’s not like anyone’s not at risk for this. It doesn’t work like that.

Samantha: And we’re giving prevention to 100% of patients. And that we’re aware of it, we’re thinking about it, we’re doing all the prophylaxis automatically to try and optimize outcomes.

Dr. Nathan: Exactly. And I think that the other thing is, even though that sort of sounds scary, that there’s anyone can have it, this, that, there are so many options for treatment. And since it’s something that we think about and prepare for and know how to treat and treat all the time, the likelihood that it’s going to lead to something bad is very, very low. And again, typically the first “bad” thing that it’s going to be is just you got an extra medicine, and maybe you got a blood transfusion. But that’s actually not bad. It’s just sort of like indicates you bled more.

The likelihood you’re going to need something like a surgery or a hysterectomy or something crazy, is really, really, really, really low fortunately, except very specific circumstances that we talk about, you know, someone has an accreta on five prior C-section. I mean, there’s situations where we tell people, “All right, this is like a real possibility.” But for everybody else, it’s a low probability and a very, very low probability that something bad is gonna happen, again, because this is something that we all train for. I mean, this is one of the major things you train for, like, you learn how to deliver a baby, learn how to do C-section, you learn how to treat hemorrhage. Like, those are like the first three things you learn how to do on a labor floor.

Samantha: And paying attention to it matters. On the flood for California, the CMQCC with it is really great [inaudible 00:41:51]. Like, paying attention counts, and it really is effective when hospitals influence strategies, have massive transfusion protocols, have hemorrhage carts. It gets better. It’s something we can really treat and manage.

Dr. Nathan: We could take Sam out of California, but we can’t take the California out of you. We haven’t beaten it out of you yet.

Samantha: Yeah, the good bagels, though, are working.

Dr. Nathan: I understand: The bagels are good here. Excellent. Well, Sam, thanks so much for coming on. This is a great topic to talk about. I’m actually surprised we didn’t talk about it until now. We’ve been a full year on the podcast and didn’t hit hemorrhage. It’s like, I can’t believe it. I just forgot. You know, you’re delivering babies, I’m delivering babies, we’re thinking about this, everyone’s thinking about this. It’s a great thing.

If you’re, you know, you as a listener, you’re curious, you know, why are they doing this? Why are they doing that? Why are they so worried about it? You know, hopefully this will help clear some of that up and hopefully, overall, lower the fear for this because again, outcome should be really, really good because this is something that we take care of all the time.

Samantha: It’s something we definitely know how to manage. Thank you so much for having me on.

Dr. Nathan: Awesome. Thank you for listening to the Healthful Woman podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

Man: The information discussed in Healthful Woman is intended for educational uses only. It does not replace medical care from your physician. Healthful Woman is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.