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!

Martha I found this article really good for helping me to understand why a negative hospital existence may not have occurred at home - I think it specifically uses PPH as an example.

erinmidwife.com/2011/03/31/if-i-were-at-home-i-would-have-died/

Obviously each birth is individual but it was interesting to me.

I am having a HB against my consultants advice. I had a 3c tear and have ongoing problems so she'd prefer me to have a cs rather than vaginal birth. There is no risk to the baby and my risk of a repeat tear is about 5% so i decided it was a risk worth taking.

Having said that, none of the NHS midwives I saw were very supportive. They claimed my notes made them "twitchy" so I called an independent midwife for her opinion.

I have since decided to book the IM as I need my midwife to have confidence in me in labour.

Could you call an IM for their opinion? Or send an email to the Homebirth Yahoo group. There are many knowledgeable women on there.

Good luck, I'm hopeful for you.

Thanks idlevice, scaevola, iggly and kellykettle for your posts.

idlevice - I'm so sorry you lost that amount of blood, it sounds like an awful lot. I can imagine you are quite grateful to have been in a situation where you felt the right people were on hand to help. Yes, I do need to think cautiously and I do need to look at the risks. If anything your post has highlighted how important it is for me to get hold of my notes from the previous birth - I don't really want to make any assumptions at all if I can help it.
I don't know your situation at all but I'm curious to know if you have at all the same feeling as I do about the complications that arose: do you feel like they could have been avoided if earlier interventions hadn't taken place? That is a very strong feeling that I have but of course I'll never ever know!

scaevola I was wondering what the sequelae of a pph could be (aside from death) ? Are they better equipped in hospital to help if there is a very very dangerous pph? Is it just that in hospital you may have quick access to a transfusion? I'm sorry for all the questions but I really don't know.

lunarose, notsuchayummymummy and iggly Thanks for sharing your stories with me. Again, they all show me that I shouldn't make assumptions about my previous pph and it's really important to be aware of what happened last time.

kellykettle thanks for the link! A good article. Yes, I have been considering trying to talk to an independent mw - I don't think I could actually afford to have one, I just would like to get a few different points of view. Actually, when I was at my booking in app and my husband asked what would happen if we went to a private mw, the mw said ' oh she would of course allow you to have a homebirth if that's what you wanted'. Actually, this shook me too because I thought 'if it's as dangerous as you are making it out to be, then surely any mw would echo your concerns, regardless of her afflilation or how much money she was being paid'.

Thanks again everybody, it's enourmously helpful.

I genuinely do not understand why after not a complication free first labour you would want to risk a homebirth.....

Theposieparker I guess because I genuinely believe that my complications arose from being in the hospital. I never felt safe, I felt abandoned and terrified. The idea of being put in that situation again makes me very, very anxious.

mathamay The one thing I did forget to mention was they (paramedics) virtually immediately put a line in with fluids. I can only assume this was (and I really am assuming here) because they spoke to a m/w at the hosp- and they advised them of previous pph? I'm pretty sure its not something they do routinely?

This thread has been helpful/confusing, as wasn't something I'd considered until now. I'd also like a homebirth, for very similar reasons as you, and my midwife has no problems with it, despite a PPH of 1200ml during previous birth.
No-one at the hospital during the birth mentioned the PPH at any point, it was only on reading my birth notes at home afterwards that I found out about it. My current pregnancy has been classified as normal risk.
I don't know if anyone will have a straight answer for you - from reading your post it sounds like the whole combination of issues at previous birth has made you 'high-risk' not just the PPH itself. Good luck in trying to reach a decision.

You should join the UK Midwifery yahoo group and post your query there; they are excellent.

FWIW I had a larger blood loss than yours and had a transfusion after DC1. I then had a homebirth with DC2. However, I suspect that the nub of the issue is what caused your pph?

Apols if you've already explained this, I'm dashing off so no time to read the whole thread.

Good luck!

That's interesting notsuchayummymummy - so they were definitely geared up to helping you if the situation got serious.

I just read that the average vaginal birth leads to blood loss of 500mL. I only just lost that amount - if it's average, why am I high risk?

There are only two types of risk when assessing mums to be - high and low. My midwife reluctantly marked me as high risk as there was no "medium" option, because of the PPH.

I suspect that if you had not been asking for a homebirth, you would still be classed as low risk and under MW only care

Agree with PPs that the yahoo groups may be useful - uk midwifery, homebirth uk and HBAC/VBAC groups all fab.

Do be aware, that you can decline the cons appointments if you wish. And you can discuss it the the MW, do your own research, then still plan a homebirth if you feel that is best. They do not give you 'permission' to have your baby at home.

With such a small PPH, personally it would not change my plans. But then I planned a homebirth after a crash section/GA first time round and I am also a HCP

One thing to consider - maybe speak to the MW about the previous birth - it may well be that the cause of the PPH was the failed ventouse/forceps and with a nice spontaneous birth without these you may be less likely to have extra bleeding. That said, if you did bleed you could transfer in - it may well be worth considering having the baby at home and going in after if needed , rather than go in just in case

IME many complications are caused by having babies in hospital, who then get the credit for putting the complications right again.

Hi

Im not sure that PPH can be put down to any hospital intervention. With my first DS I was induced after spontaneous rupture of membranes but he was born with no intervention so to speak only an episiotomy. I had a small PPH. I already had a line in due to induction drugs and they gave the synctocin ?? v quickly.

With my second child my DS I went into full labour naturally, v straightforward only in hospital 2 hours before she was born and I had a bigger PPH, no line in this time and DH remembers me being laid flat given oxygen and a number of midwives rushing round putting line in and giving me numerous injections to stop it. No intervention at all with the birth and I have always assumed it was something in the way my body reacts?

Interestingly my mum had a PPH with me.

If I had a third child I would be much happier in hospital given my history and my experience is labour a second time around when you know what you are doing is a much better experience.

S

this and this discuss instrumental delivery as a risk factor for PPH

homebirth site info about PPH

NICE guideline for intrapartum care also mentions operative birth as a risk factor.

Forceps delivery may be a coincidence, not everyone with PPH has a known risk factor of course, but worth bearing in mind.

The article I linked makes the connection between PPH & induction (specifically syntocinon). I think also the environment - feeling unsafe, reduced hormonal flow (oxytocin) means uterus doesn't react the way it should to push out the placenta. I don't think the hospital link has to be just instrumental delivery.

It's a tough decision because you're making a best guess really. But if that's an informed one then I am certain you will choose what's right for you & your baby.

I had a 750 pph. Birth was in hospital, but no intervention at all - it just happened (birth and blood loss!),
First thing community mw said on home check up was 'oh you'll have to go for a home birth next time, you're a quick and easy one'. I assume she'd read my notes, so it sounds like your mw is just looking for an excuse.

All interventions (not just instrumental) carry a risk of increased PPH.

I had a PPH of 500ml with DS1 in hospital after ventouse and my iron levels were low. This was never raised as an issue when I said I wanted a HB with DS2 (and believe me, everything that could possibly have been an issue was raised - rightly so). I went on to have a home water birth and lost 50ml according to my notes and I'm not even sure where they got that figure from as the water was completely clear and not red.

Sorry, pressed post too quickly - meant to add that if my health authority was ok with 500ml you are well within your rights to challenge yours.

A good friend of mine had 2 awful births and on her 2nd nearly died.
(both hospital) she had a severe PPH at the end of birth 2.
Her 1st she had loads of intervention and ended up with a EMCS.
Had nasty tears etc etc

She is adament that the reason her births went wrong in the 1st place was because the hospital made her do things which are not great for a natural birth, and she spent most of labour lieing still on her back on a bed, and then with her legs in stirrups etc etc.

She did NOT want a repeat of this with her 3rd, and the midwifes practically laughed at her when she mentioned she would like a home-birth as "they did not want to be dealing with a dead lady and 3 children without a mum".

She never saw an NHS midwife after that, and went independant. (she lived at least 30mins ambulence ride from hospital)

Her IM was very very supportive and agreed that the positions she had been put in and the intervention / monitoring she had accepted had almost certainly led to her pretty horrendous births, and was absolutely fine about her having a home birth.
They also discussed going to hospital and of course my friend agreed that if IM decided it actually was necessary to transfer then she would

She got her pool ready, and knew that IM was always around except for 1 day during the due date window when she was attending a wedding.....
Obviously baby chose that evening to be born. My friend hadnt realised she was in labour, until very late when they called the IM, who was heading home anyway. She went to the loo and her DH saw the head .... she got in the pool and with just her DH delivered her 3rd baby. No pain relief, no tearing,

she sat with him for a while in the pool then got out. Her IM arrived as the placenta delivered naturally. and then the chord was cut etc etc.

My friend has been one of the most supportive people in my planned homebirth (Im 37+6 with my 1st, so waiting and ready )

Just cause the NHS think you are mad, you dont have to go along with it. She really wished that she had homebirthed all of hers, with an IM.

She found several local enough IM's who were more than happy to support her in the birth she wanted, and had her pick

marthamay: yes, being in hospital gives ready access to large stocks of transfusable blood and also to operating theatres (emergency surgical intervention may be required depending on cause of the bleed). The main risk is bleeding to death, occasionally there can be impact on other organs resulting from sudden drop in blood pressure (but this isn't usually fatal).

I really do think you need to talk to your consultant about this, with a debrief of your previous birth. Not just the site of the PPH, but also why interventions were used in the delivery. If there is a possibility (obviously backed by evidence) that your baby might again need intervention for safe delivery, then is HB really the option? Not all instrumental deliveries are for iatrogenic reasons - find out about yours. Transfer when a baby is already in distress is associated with worse outcomes for the child.

marthamay, just reading back again

yes i understand it midwives ARE trained to deal with PPH, and have a procedure (I forget what its called) which is pretty unpleasant and many may only use once or twice in their career, and although its unpleasant it should keep you alive while you transfer by ambulence to hospital.

hence the need to for 2 midwives at a home-birth..... one to do this for the whole ambulence ride, and one to look after the new baby who may also need some care, while midwife 1 uses both her hands to stop you dieing.

i cant imagine its very nice and probably terrifiying for all concerned, but it does exist and can be used. the midwife and ambulence crew wont just sit there and watch while you heamorage to death...

Ambulences also carry transfusable blood dont they? I have IV fuids in my homebirth pack too... clearly not blood, just saline, but its still there and ready...

Yes, I do think intervention may well have contributed to my PPH, but I don't think there was much alternative to having the interventions: I was 2 weeks overdue, posterior baby, only 2cm dilation after 48hrs spontaneous labour & babe was in a position where his heartbeat could not be monitored even by the tummy band in hospital so it was pretty worrying. If I had for some reason been having a homebirth no doubt I would have wanted to be transferred to hospital anyway. I had augmnentation by syntocinon, which I do believe is vile but a necessary evil in some cases.

I went over my notes with an independant obstetrician. He did not feel he could attribute a definite cause to the PPH & settled for one of or a combination of three possible factors, two of which (second degree tear and uterine atony) could well have been related to the intervention. But there are random causes of PPH which are pretty scary (uterine artery rupture sounds the worst!!) & having been through massive PPH I personally wouldn't take any risk again. Feeling adequately informed about the decision is the first place to start so going through your notes would be a great idea.

Just another pph story for you. A very good friend of mine had a perfect birth, no intervention, followed by a pph that needed surgery to stop. She needed 7 pints of blood (and she's tiny) and was in intensive care, separated from her baby, for 3 days. Please don't underestimate how serious it can be.

Hmmm.

Given that PPH does regularly happen to mums with no history of or risk factors for PPH, you'd have to ask yourself why home birth is considered 'safe' at all. Looking at a study from the Netherlands, 4% of low risk births were complicated by a 'severe' PPH, usually linked to retained placenta or abnormal third stage.

I can only assume it's because when a PPH does happen at a home birth it's usually effectively managed and hasn't in the past resulted in maternal deaths or severe morbidity.

OP - if I was you I'd contact the supervisor of midwives at your local hospital - that's the usual thing to do if there is any conflict about the way you want your care to be managed. If they don't have a supervisor of midwives then contact the head of the community team.

"hasn't in the past resulted in maternal deaths or severe morbidity."

When I say 'in the past' I mean since women were attended at home by a properly trained midwife with a back up ambulance service!

So Sorry about your loss, LF.

May I ask, was yours a planned hospital birth? Did the blood loss all happen very suddenly, or did you have hints of things going wrong over an hour or more? I think that's what OP needs to know, if MWs at a homebirth would have time to assess the situation and get her to hospital in time to do what little can be done.