Advised against a homebirth due to previous (minor - 500ml) pph...?

[marthamay]

Hello,
I was wondering if anyone had any thoughts on this.
Yesterday I had my booking in app for my 2nd pregnancy. When I mentioned wanting to have a home birth the midwife was initially very supportive but then when she went and checked my previous birth notes she noted that I had had 'complications': failed ventouse followed by forcep delivery and episiotomy. It was also noted that I had a post partum haemmorage (spel?) and lost 500mL of blood and my blood count went down to 8. I didn't need a transfusion thankfully and felt fine within a few days.
The midwife led me to believe that this was a very serious complication and that I would now be considered 'high risk' and therefore would need to be under obstetric consultant care and really gave me the serious doom and gloom about it all.
I have to admit that I was a little shocked and got quite upset. I found my first birth incredibly traumatic. I am actually quite terrified about the prospect of going back into hospital for my second birth. What really upsets me is that mistakes that I felt were made in my care the first time around (that I strongly feel led to the assisted delivery and pph) are still reverberating so strongly in my life to the point where they are going to control how I have my 2nd birth!!!!

When I came home yesterday I started looking into pph and have discovered that 500mL is the minimum amount that can be classed as a pph - so maybe my midwife was being a little alarmist???(or is this completely naive of me?)

So anyway, I've got a long way to go yet and am trying not to let the whole thing make me anxious. I just want to do as much research as possible into the matter and try and to make an informed decision.

I guess I'd like to know if anyone has had a similar experience or has done any research of their own into this matter - or if anyone has gone on to have a homebirth after a previous pph?

Also wondering if I do decide to ask for a homebirth, how do I stay strong in my decision if people (mw and consultant) advise me otherwise?

Sorry for long and rambling post, my head is all over the place!

I am in a similar situation...my second birth was great, really fast and easy, but after delivering the placenta, there were a few clots so they put me on a drip of syntocynon to help my uterus clamp down. It didn't feel like a big trauma just an inconvenience as I had to have a catheter too. I didn't think anything of it until my booking appt for this pregnancy when my midwife said it was a PPH of 500ml and that I would have to see a consultant. I wasn't planning a homebirth (but was planning on having the homebirth kit at home just in case I labour even faster this time round), but the consultant wants me to deliver at the hospital and have the drip put in as soon as I have delivered to avoid another PPH. I'm not too fussed about delivering at the hospital because I was lucky to have a good experience last time.

My first birth was a slow induction with loads of interventions etc and I was dreading the second birth.....but the second birth was loads easier, despite being in hospital. The funny thing is that my partner reckons I lost more blood the first time round (based on what he saw) and that he saw hardly any the second time!

Really?

I had a 700ml PPH after having DD (along with 3a tear, forceps, and manual removal of the placenta) and I am planning to have a homebirth with no2. In fact (much to DH's disappointment I think) I am prepared to be bloody bolshy about it and stick to my guns unless there is a medical problem with the baby at term requiring me to go in. I think that every single issue was related to the syntocinon induction - why would I want to go into hospital and increase the risk of any of those issues a second time? (rant over!)

The WHO (I believe) are trying to get the level of loss considered to be a PPH raised to 1000ml, so I can't imagine 500ml would be a particular worry.

Have you looked on this site - very helpful. Remember, they can't make you go into hospital if you don't want to, and that the decision is ultimately yours. You could go and chat to the consultant though (probably nearer the end of pregnancy) and he/she will advise you to go to hospital, although consultants don't deal with normal births by the very nature of their job and are therefore more likely to err on the side of extreme (and sometimes unnecessary) caution.

I'll be watching your thread with interest, to see how many others have had the same experience :)

Do you know, I can feel myself getting wound up already about the thought of having to fight over this :(

traumatic births are really hard. I'm a doctor, and have worked for a short time on a labour ward. It may be possible to discuss with a doc or a senior midwife what happened in your first delivery, as discussing what happened last time, and the concerns for you this time may make you think differently, or come up with a shared plan that you feel more positive about.

If I had bled 500ml in the past and my blood count gone down to 8, I personally would be happier in hospital delivering- the risk of this happening at home, and being worse might mean a blood transfusion and a longer stay in hospital, and feeling pretty ropey with a low blood count.

Obviously I see this through the eyes of someone who has mainly been involved with mothers and births where things aren't all tickety boo (otherwise midwifes would manage it all)...

Good luck with it though... hard but exciting times!

My blood count wasn't checked after birth either, and I was still prescribed iron tablets.

hi super sunny really hard to comment about the blood counts without knowing the exact details, and sometimes doing the test doesn't change what you'd do (if you don't feel someone's unwell enough for a transfusion, but they've lost a lot of blood, probably it's sensible to be on iron supplements), but on the whole, if someone has been diagnosed with PPH, then I suppose yes, I'm surprised they didn't check a blood count, but there are probably lots of people who know better than I.

I feel lucky that I'm so comfortable around medical environments, and that for me I feel confident in the midwifery staff on my local labour ward, and safer in a medical setting. I can totally see how women would rather be at home, but having seen how quickly things can go pear shaped, like Super Sunny says, I'd rather be closer to what's kept in those medial cupboards!

Thank you everyone for your responses! It's really good to hear a few different opinions too.
Flisspaps - Have you spoken to any midwives yet? I'm really curious to know if there is a range of opinions out there and whether some are more supportive than others. It's really, really hard not to get worked up about it isn't it!!! I also feel that my pph was most likely (although I do need to check this out) caused by damage to the vaginal area from the assisted delivery rather than a retained placenta or anything else and I think home births in general have a lower statistical risk of ending in an assisted delivery - so shouldn't it make sense to lower my risk of that also?

littleshinyone thank you so much for sharing your views, I find it very interesting. Actually the midwife yesterday did mention that if I had a hospital birth she thought it very important that I talk directly to the senior midwife at the hospital as well as the consultant to come up with plan that I felt good about. The thought that I might have people on my side does make me feel a lot better about the prospect of being in hospital - I'm just not sure that I trust the situation. I will feel a lot better when I have talked to them though.

I know in my previous pregnancy, my blood level was pretty low before I went into Labour because there was talk about iron tablets - at the moment my iron levels are excellent (14) and if I can maintain them a bit better this pregnancy maybe my risk would be decreased?

Do you know whether the risk of pph increases with each subsequent birth???

supersunnyday I would love to be in the MLU ( it's the one attached to the JR in Oxford)!!! Actually I would feel that it was the perfect compromise but I'm in the same boat as you because of previous birth they won't let me! It's silly....

Are midwifes not at all trained to deal with a minor (500-1000mL) pph???? It must be a relatively common occurrence. Again, maybe I am being quite naive about all this.

I forgot to say in my first post that the midwife was lovely about it all and didn't seem threatening or bullying at all, just very concerned that I was aware of risks and keen to make me aware that she would NOT recommend a HB. I'm not sure how she would react if I decided I wanted to anyway but I do hope that she'd support me in that too.

First time round i had a ventouse delivery, retained placenta and had to have a couple of units of blood transfused.
I was determined to have a home birth with dd2, and had to be pretty firm about it but got my own way. I had an appointment with the consultant at 36 weeks because of the issues the first time and he tried to talk me out of it but in the end it was my decision and I stuck to it (we also live within 10 mins of the hospital, which helped).
And it was brilliant. Best decision I ever made. Much shorter labour, and so much better being at home. Fabulous

Similar experience: 750ml pph with DC3 at homebirth. Due, I think, to things I could have done differently. MWs dealt with it fine, btw, but transferred me in to hosp when my BP went quite low, due to dehydration, I think. I had refused blood tests throughout pregnancy with DC3, too, that was half their concern, but my iron levels were fine when they tested so I went home with only iron pills (which I didn't take anyway, they give me the runs).

Neglected to mention the pph or transfer when I was booked in with DC4 (naughty ). So Had DC4 at home with a very low postpartum low blood loss, no problems or regrets.

If you want support for a homebirth you must get yourself onto the homebirth Uk email list. They are brilliant.

PS:, my iron levels in hosp test after the pph with DC3 were so good that both doctor & I thought it was a fluke, ie: probably a wrong reading. But I felt fine by the time results were in & was happy to be discharged.

supersunnyday oh really?! I was supposed to go to the spires for my first birth and was SO excited about it....grrrr... it is lovely and would be a great place to give birth I think.
I've read your thread with interest. Have you managed to work out how to get hold of your notes yet? I think I am going to try and get hold of mine. It might be good for me to look again at why I feel so traumatised by my first birth, maybe try and deal with it a bit better before starting to think about this little one.

catissleepy and ragged - Great stories!!! Very, very encouraging.
I joined the homebirth UK email list today but haven't yet had an opportunity to look at it properly.

I wouldn't have brought up ANYTHING with my midwife except my DH (in loving concern!) brought it up which prompted her to look at my notes! I nearly hit him. BUT, in a way I am glad it has come up so early. At least I have the chance to get my head around things - it would be awful if this happened only weeks from Duedate.

I should mention that I live about 5 -10 minutes away from the hospital. For me, the close proximity is a huge reason to go with a HB.

I had a 1500 ml PPH with DS and I personally wouldn't have wanted a homebirth with DD. But at her birth I had a 450ml blood loss and that was never considered to be a PPH. Your blood count does sound quite low though - after DS I think mine was about 7.5 and I did had a transfusion. Sounds like the mw is erring on the side of caution but I don't know enough to know whether it is sensible or not.

I had a big pph of 1500ml with first hospital birth, then an unplanned homebirth with second baby(due to speed of labour 2hours 25 mins) and this time a bleed of about 500ml. I wanted a homebirth again for third but consultant advised against it. Midwife manager visited me to ensure I knew the risks, which were that apparently I was at greater risk of another pph as I had one at second birth for no obvious reason and chances of a bleed get higher the more pregnanies you have.

However - she made it very clear from the start that they would support me in having a high risk homebirth if that's what I wanted. Even the consultant said this too.

If you start to bleed they need to get a line into your hand to give fluids - only 1 midwife in the whole team could do this and most paramedics can't either, therefore they recommended hospital birth with line in at the start of labour.

In the end, as I live 30 mins away from hospital which I felt was a long way, I had hospital delivery - just - got there 11 mins before birth and no pph this time, just a bleed of about 400ml which is fine. No time to get a line in either - and no injection for 3rd stage as I changed my mind!

You can actually insist on a homebirth - it is your right to do so - and they have to support you. Just make sure you have all the information before you make your decision. At the time I felt it was too great a risk, but then had a fab hospital birth - and although I don't plan any more babies, if I do have one it will certainly be a homebirth again. (Mainly because there won't be time to go anywhere!)

How near are you to the hospital? That was what made my mind up in the end.

Good luck

You totally have my sympathy on the horrible horrible birth.

BUT I was all for home births and birthing units until I gave birth to DS. I when delivering the placenta they at first only managed to deliver half. there was a hushed and worried 5 mins as they tried to deliver the other half and debated whether to hold the ambulance (that had just arrived to transfer another mum) for me too. As it happened it delivered fine, but at that moment I was suddenly faced with the possibility of an emergency transfer, in a lot of pain, and being at least 20 mins from even being in the right place for the help I needed right now. It really wasn't a good moment.

Personally now I would always choose a hospital birth (with a very stroppy birthing partner to look out for me )

marthamay No, my booking in appointment isn't for another 3 weeks yet - am only 6+5, but am preparing for the resistance early on. I wanted HB with DD and eventually gave in to induction at 40+14, which I regret.

Hi there, congrats on your pg.

I just thought I would say that I had a PPH of 1000mls for DC1 which I put down to long long labour, epi and assisted delivery (much the same sort of thing you had).
DC2 - well it all happened a bit quick! Yes I had been told to labour in hosp because of various complications but it just did not happen that way. DC2 arrived on the bathroom floor after a very quick unassisted labour (tho a paramedic had arrived in time to catch the baby). I still PPH'd - this time only 800mls. All I am saying with that is dont assume (as I did) that the assisted birth was responsible.
After the first birth I felt shocking for days and days after - I now realise from the blood loss. After DC2 I felt fine (!) and the cons at the hosp didnt seem to believe that I was walking round fine and wanting to go home.....
However I had been taking Pregaday and Spatone from 20 wks because I was anaemic - and I know the mw thought thats why my blood count was better after delivery than at 20 wks.
I'm rambling I know but just thought I would give you my experience.

Re the PPH at home - it did apparently cause a bit of excitement at the time - but the cmw arrived just at the right time to give me synto and stop the bleed - otherwise I would have been blue lighted - but it was all fine as it goes.

From a medical point of view, having had a previous PPH does increase the risk of another one: erring on the conservative side, it would be prudent to assume the PPH was due to an underlying reason which hitherto was not known about and now after the first experience it is known about, even though what the exact cause is may still remain unknown. That assumption may be completely invalid but it would be the most cautious approach to take. PPH can be very severe as the bloodflow aorund the uterus can be up to half a litre a minute at the time of birth so it certainly should be weighed up very seriously. I speak as someone who lost 3litres & would have perished or left very damaged if I hadn't been in hospital so I can't help be on the pessimistic side!

yy to idlevice - sequelae of PPH are avoidable disastrous risks.

Basically, you can bleed to death before you can get to hospital Even if blue-lighted, and syntometrine is not necessarily a sufficient treatment - in the "olden days" even the obstetric flying squad (who were very experienced and all equipped to deal with this) couldn't always save the mother.

Working out how likely an individual is to have a second PPH, and the likelihood of any PPH being disastrous, is not exact.

OP: I suggest you see a consultant to discuss your individual circumstances and risk profile. It is then up to you to make your own decision about the level and nature of risk you are prepared to run. As noted by posters above, there are organisations etc who will help you stand your ground.

I had a PPH at home (1000 ml) and was am wary of having another home birth - but partly because I have a toddler too!

From what I understand, I thought the risk of a subsequent PPH depends on what caused it first time around. So something like fibroids vs having a third degree tear are different causes but might not be a problem second time around.
My PPH was due to DS arriving with his elbow up by his head - I was pushing for two hours (although active labour itself was 10 hours including pushing). Uterus contracted fine.

When I saw a consultant she wasn't fussed about the PPH, more about the third degree tear (where I lost the blood) and was fine for me to birth at home second time around. I haven't decided yet TBH.